Provider Demographics
NPI:1609476373
Name:CLIFFORD, TRACEY LYNN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LYNN
Last Name:CLIFFORD
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 1:7162 W SR 46
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201
Mailing Address - Country:US
Mailing Address - Phone:812-447-1206
Mailing Address - Fax:
Practice Address - Street 1:2025 MERCHANT MILE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-1572
Practice Address - Country:US
Practice Address - Phone:812-376-9385
Practice Address - Fax:812-376-9417
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017715A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist