Provider Demographics
NPI:1841731205
Name:EDER, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:EDER
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 1:12250 WOLVERTON WAY
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4411
Mailing Address - Country:US
Mailing Address - Phone:317-501-7356
Mailing Address - Fax:
Practice Address - Street 1:150 MARLIN DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1451
Practice Address - Country:US
Practice Address - Phone:317-885-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021782A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist