Provider Demographics
NPI:1659414639
Name:PAVLICEK, TRACEY L (RPH)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:PAVLICEK
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 1:2260 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2414
Mailing Address - Country:US
Mailing Address - Phone:701-483-9299
Mailing Address - Fax:701-225-0013
Practice Address - Street 1:363 15TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3017
Practice Address - Country:US
Practice Address - Phone:701-225-4434
Practice Address - Fax:701-225-0013
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist