Provider Demographics
NPI:1598050403
Name:HIETT, TRACI DAWN (PHARMD)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:DAWN
Last Name:HIETT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1728
Mailing Address - Country:US
Mailing Address - Phone:304-257-2072
Mailing Address - Fax:304-257-1506
Practice Address - Street 1:50 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1728
Practice Address - Country:US
Practice Address - Phone:304-257-2072
Practice Address - Fax:304-257-1506
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007129183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist