Provider Demographics
NPI:1639345820
Name:FIRST, TRACIE RAYE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:RAYE
Last Name:FIRST
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 1:20 SW 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-3105
Mailing Address - Country:US
Mailing Address - Phone:954-421-9453
Mailing Address - Fax:
Practice Address - Street 1:20 SW 12TH AVE
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-3105
Practice Address - Country:US
Practice Address - Phone:954-421-9453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS26766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist