Provider Demographics
NPI:1790772473
Name:TRACYS MEDICINE CENTER
Entity Type:Organization
Organization Name:TRACYS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SHANNAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-939-1642
Mailing Address - Street 1:3171 TUCKER NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2124
Mailing Address - Country:US
Mailing Address - Phone:770-939-1642
Mailing Address - Fax:770-723-9515
Practice Address - Street 1:3171 TUCKER NORCROSS RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-2124
Practice Address - Country:US
Practice Address - Phone:770-939-1642
Practice Address - Fax:770-723-9515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GAPHRE005288333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000422881BMedicaid
GA0316910001Medicare NSC