Provider Demographics
NPI:1679850937
Name:OGLESBY, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:OGLESBY
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 1:4103 PECANLAND MALL DR
Mailing Address - Street 2:T-1469
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-7009
Mailing Address - Country:US
Mailing Address - Phone:318-388-3474
Mailing Address - Fax:318-388-3474
Practice Address - Street 1:4103 PECANLAND MALL DR
Practice Address - Street 2:T-1469
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-7009
Practice Address - Country:US
Practice Address - Phone:318-388-3474
Practice Address - Fax:318-388-3474
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist