Provider Demographics
NPI:1497868947
Name:ANDERSON, TRACY SHANNON (DPH)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:SHANNON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 FIR ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-4239
Mailing Address - Country:US
Mailing Address - Phone:580-336-4474
Mailing Address - Fax:580-336-0108
Practice Address - Street 1:800 FIR ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-4239
Practice Address - Country:US
Practice Address - Phone:580-336-4474
Practice Address - Fax:580-336-0108
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK12550OtherLICENSE NUMBER