Provider Demographics
NPI:1932375599
Name:NICHOLSON, TRACY BARNES (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:BARNES
Last Name:NICHOLSON
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 1:20605 POPES STATION RD
Mailing Address - Street 2:
Mailing Address - City:CAPRON
Mailing Address - State:VA
Mailing Address - Zip Code:23829-2647
Mailing Address - Country:US
Mailing Address - Phone:434-658-4837
Mailing Address - Fax:434-348-4558
Practice Address - Street 1:306A WEAVER AVE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1232
Practice Address - Country:US
Practice Address - Phone:434-348-4987
Practice Address - Fax:434-348-4558
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011796183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202011796OtherVA LICENSE