Provider Demographics
NPI:1255936225
Name:LOKE, TRACY (ROB)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:LOKE
Suffix:
Gender:F
Credentials:ROB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 OAK SQUARE AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2517
Mailing Address - Country:US
Mailing Address - Phone:617-458-9938
Mailing Address - Fax:
Practice Address - Street 1:367 RUSSELL ST.
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-9456
Practice Address - Country:US
Practice Address - Phone:413-586-6681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0015333183500000X
MAPH239693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist