Provider Demographics
NPI:1831673623
Name:PERRIE, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PERRIE
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 1:4400 PALUXY DR APT 1035
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-2152
Mailing Address - Country:US
Mailing Address - Phone:817-703-2932
Mailing Address - Fax:
Practice Address - Street 1:4400 PALUXY DR APT 1035
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2152
Practice Address - Country:US
Practice Address - Phone:817-703-2932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0000000000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000000OtherNA