Provider Demographics
NPI:1790372324
Name:CARROLL, TRACY (RPH)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CARROLL
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 1:19 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:JIM THORPE
Mailing Address - State:PA
Mailing Address - Zip Code:18229-2518
Mailing Address - Country:US
Mailing Address - Phone:570-325-5668
Mailing Address - Fax:
Practice Address - Street 1:1204 NORTH ST
Practice Address - Street 2:
Practice Address - City:JIM THORPE
Practice Address - State:PA
Practice Address - Zip Code:18229-1726
Practice Address - Country:US
Practice Address - Phone:570-325-5020
Practice Address - Fax:570-325-5028
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP039263L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist