Provider Demographics
NPI:1922444041
Name:MOCK, TRACY (RPH)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:MOCK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:ZERBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1401 GALAXY DR NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-4746
Mailing Address - Country:US
Mailing Address - Phone:360-456-7862
Mailing Address - Fax:
Practice Address - Street 1:1401 GALAXY DR NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-4746
Practice Address - Country:US
Practice Address - Phone:360-456-7862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00018024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2026868Medicaid