Provider Demographics
NPI:1962496166
Name:TRACY MEDICINE OF ATLANTA GA INC
Entity Type:Organization
Organization Name:TRACY MEDICINE OF ATLANTA GA INC
Other - Org Name:MEDICINE CENTER OF ATLANTA, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:770-934-7703
Mailing Address - Street 1:3650 CHAMBLEE TUCKER RD
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341-4420
Mailing Address - Country:US
Mailing Address - Phone:770-934-7703
Mailing Address - Fax:770-414-1463
Practice Address - Street 1:3650 CHAMBLEE TUCKER RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-4420
Practice Address - Country:US
Practice Address - Phone:770-934-7703
Practice Address - Fax:770-414-1463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4501332B00000X
GA15042333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1107588OtherNABP NUMBER
GA1107588OtherNABP NUMBER