Provider Demographics
NPI:1578860615
Name:COLLINS, TRACEY MOATS (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:MOATS
Last Name:COLLINS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-5834
Mailing Address - Country:US
Mailing Address - Phone:803-419-3664
Mailing Address - Fax:
Practice Address - Street 1:9001 TWO NOTCH RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5834
Practice Address - Country:US
Practice Address - Phone:803-419-3664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist