Provider Demographics
NPI:1629579636
Name:BROOKS, TRACY LEIGH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LEIGH
Last Name:BROOKS
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 1:13717 PUFF RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9682
Mailing Address - Country:US
Mailing Address - Phone:260-615-5539
Mailing Address - Fax:
Practice Address - Street 1:11109 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-672-4045
Practice Address - Fax:260-672-4517
Is Sole Proprietor?:No
Enumeration Date:2018-02-25
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020072A1835P1200X, 208VP0000X, 1835P0018X, 101YA0400X, 1835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support