Provider Demographics
NPI:1740587450
Name:ERVIN, TRACEY LYNN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LYNN
Last Name:ERVIN
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 1:1415 OTTER LAKE LOOP
Mailing Address - Street 2:
Mailing Address - City:HANSON
Mailing Address - State:KY
Mailing Address - Zip Code:42413-9332
Mailing Address - Country:US
Mailing Address - Phone:270-322-0756
Mailing Address - Fax:
Practice Address - Street 1:444 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-2846
Practice Address - Country:US
Practice Address - Phone:270-821-4999
Practice Address - Fax:270-821-0070
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY013225183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist