Provider Demographics
NPI:1205149358
Name:WILSON, TRACEY B (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 WOODBURY GLASSBORO RD
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-3733
Mailing Address - Country:US
Mailing Address - Phone:856-415-2381
Mailing Address - Fax:856-415-2391
Practice Address - Street 1:675 WOODBURY GLASSBORO RD
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-3733
Practice Address - Country:US
Practice Address - Phone:856-415-2381
Practice Address - Fax:856-415-2391
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03124900183500000X
FLPS27099183500000X
DEA1-0003691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist