Provider Demographics
NPI:1659047850
Name:CARLSON, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CARLSON
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 1:15 WOODBRIDGE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1312
Mailing Address - Country:US
Mailing Address - Phone:732-596-3245
Mailing Address - Fax:732-596-3298
Practice Address - Street 1:15 WOODBRIDGE CENTER DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-1312
Practice Address - Country:US
Practice Address - Phone:732-596-3245
Practice Address - Fax:732-596-3298
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02632400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist