Provider Demographics
NPI:1972855005
Name:STREET, TRACY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-4737
Mailing Address - Country:US
Mailing Address - Phone:207-857-9298
Mailing Address - Fax:207-857-9304
Practice Address - Street 1:31 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4737
Practice Address - Country:US
Practice Address - Phone:207-857-9298
Practice Address - Fax:207-857-9304
Is Sole Proprietor?:No
Enumeration Date:2012-10-13
Last Update Date:2012-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist