Provider Demographics
NPI:1669876264
Name:HUMPHREYS, TRACY (RPH)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 MARKET PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-4916
Mailing Address - Country:US
Mailing Address - Phone:425-377-7110
Mailing Address - Fax:425-377-7128
Practice Address - Street 1:8915 MARKET PL
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-4916
Practice Address - Country:US
Practice Address - Phone:425-377-7110
Practice Address - Fax:425-377-7128
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00014867183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist