Provider Demographics
NPI:1457954166
Name:RODE, TRACEE NICOLE
Entity Type:Individual
Prefix:
First Name:TRACEE
Middle Name:NICOLE
Last Name:RODE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 E JONES PIT RD
Mailing Address - Street 2:
Mailing Address - City:BRUCEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47516-6164
Mailing Address - Country:US
Mailing Address - Phone:812-887-7446
Mailing Address - Fax:812-254-1360
Practice Address - Street 1:307 E NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4040
Practice Address - Country:US
Practice Address - Phone:812-254-6298
Practice Address - Fax:812-254-1360
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020741A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist