Provider Demographics
NPI:1720516255
Name:BLANTON, TRACEY LEE (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LEE
Last Name:BLANTON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MS
Other - First Name:TRACEY
Other - Middle Name:LEE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6200 N LA CHOLLA BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3529
Mailing Address - Country:US
Mailing Address - Phone:520-469-8690
Mailing Address - Fax:
Practice Address - Street 1:6200 N LA CHOLLA BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3529
Practice Address - Country:US
Practice Address - Phone:469-469-8690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-29
Last Update Date:2017-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ018029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist