Provider Demographics
NPI:1457762916
Name:WOLFE, TRACY (R PH)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:WOLFE
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 DON KNOTTS BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-6734
Mailing Address - Country:US
Mailing Address - Phone:304-225-7979
Mailing Address - Fax:304-225-3784
Practice Address - Street 1:215 DON KNOTTS BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-6734
Practice Address - Country:US
Practice Address - Phone:304-225-7979
Practice Address - Fax:304-225-3784
Is Sole Proprietor?:No
Enumeration Date:2014-05-17
Last Update Date:2014-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0005412183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist