Provider Demographics
NPI:1568745446
Name:JOHNSON, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-4048
Mailing Address - Country:US
Mailing Address - Phone:740-653-7779
Mailing Address - Fax:740-653-8265
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-4048
Practice Address - Country:US
Practice Address - Phone:740-653-7779
Practice Address - Fax:740-653-8265
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03328634-3183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist