Provider Demographics
NPI:1205834637
Name:DAILEY, TRACEY R
Entity type:Individual
Prefix:MR
First Name:TRACEY
Middle Name:R
Last Name:DAILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2461 HIGHWAY 225 S
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-6042
Mailing Address - Country:US
Mailing Address - Phone:706-517-4600
Mailing Address - Fax:
Practice Address - Street 1:1100 E WALNUT AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-4183
Practice Address - Country:US
Practice Address - Phone:706-226-6000
Practice Address - Fax:706-226-3786
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH016829OtherPHARMACIST LICENSE
GA00932588BMedicaid
GA00932588AMedicaid
GAPHRE008559OtherPHARMACY LICENSE NO
GAPHRE008559OtherPHARMACY LICENSE NO
GA4482260001Medicare NSC