Provider Demographics
NPI:1598131260
Name:KIRK, TRACI LATONYA
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:LATONYA
Last Name:KIRK
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 1:1728 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-3805
Mailing Address - Country:US
Mailing Address - Phone:803-285-8491
Mailing Address - Fax:803-285-7262
Practice Address - Street 1:1728 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-3805
Practice Address - Country:US
Practice Address - Phone:803-285-8491
Practice Address - Fax:803-285-7262
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist