Provider Demographics
NPI:1710587191
Name:WILLIAMS, TRACEY LYNN
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:WILLIAMS
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 1:1313 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:HONDO
Mailing Address - State:TX
Mailing Address - Zip Code:78861-1012
Mailing Address - Country:US
Mailing Address - Phone:713-858-2925
Mailing Address - Fax:
Practice Address - Street 1:109 22ND ST
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861-2514
Practice Address - Country:US
Practice Address - Phone:830-426-3305
Practice Address - Fax:830-741-3672
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist