Provider Demographics
NPI:1457602203
Name:KOBAYASHI, TRACIE MIKA (PHARMD)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:MIKA
Last Name:KOBAYASHI
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 1:650 E AZURE AVE APT 1060
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6872
Mailing Address - Country:US
Mailing Address - Phone:808-351-5017
Mailing Address - Fax:
Practice Address - Street 1:6900 PECOS RD
Practice Address - Street 2:PHARMACY SERVICE 119
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-4400
Practice Address - Country:US
Practice Address - Phone:702-791-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0013293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist