Provider Demographics
NPI:1710573944
Name:HALEY, TRACY LYNN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:HALEY
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 1:2894 W SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-4940
Mailing Address - Country:US
Mailing Address - Phone:479-751-0882
Mailing Address - Fax:
Practice Address - Street 1:2894 W SUNSET AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-4940
Practice Address - Country:US
Practice Address - Phone:479-751-0882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD08182183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist