Provider Demographics
NPI:1902042310
Name:MATHEWS, TRACY M
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:MATHEWS
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 1:1296 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804-2603
Mailing Address - Country:US
Mailing Address - Phone:914-235-7435
Mailing Address - Fax:914-235-7485
Practice Address - Street 1:1296 NORTH AVE
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10804-2603
Practice Address - Country:US
Practice Address - Phone:914-235-7435
Practice Address - Fax:914-235-7485
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist