Provider Demographics
NPI:1609152545
Name:GRIMEK, TRACEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:GRIMEK
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 1:2204 NEVA RD
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2462
Mailing Address - Country:US
Mailing Address - Phone:715-627-7430
Mailing Address - Fax:
Practice Address - Street 1:2204 NEVA RD
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2462
Practice Address - Country:US
Practice Address - Phone:715-627-7430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI14939-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist