Provider Demographics
NPI:1912506759
Name:BRYANT, TRACER LEE
Entity Type:Individual
Prefix:
First Name:TRACER
Middle Name:LEE
Last Name:BRYANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2549 HWY 227
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:KY
Mailing Address - Zip Code:41008-8082
Mailing Address - Country:US
Mailing Address - Phone:502-732-5008
Mailing Address - Fax:502-732-5919
Practice Address - Street 1:2549 HWY 227
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-8082
Practice Address - Country:US
Practice Address - Phone:502-732-5008
Practice Address - Fax:502-732-5919
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist