Provider Demographics
NPI:1821245754
Name:JOHNSON, TRACEY RENAE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:RENAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 TIBET AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4580
Mailing Address - Country:US
Mailing Address - Phone:912-920-8046
Mailing Address - Fax:
Practice Address - Street 1:108 W HENDRY ST
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3232
Practice Address - Country:US
Practice Address - Phone:912-876-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist