Provider Demographics
NPI:1962045633
Name:WANG, TRACY KATHRYN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:KATHRYN
Last Name:WANG
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 1:845 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3049
Mailing Address - Country:US
Mailing Address - Phone:801-261-8787
Mailing Address - Fax:801-263-8523
Practice Address - Street 1:845 E 4500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3049
Practice Address - Country:US
Practice Address - Phone:801-261-8787
Practice Address - Fax:801-263-8523
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT129658-8913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist