Provider Demographics
NPI:1952905101
Name:FLANAGAN, TRACY LEANN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LEANN
Last Name:FLANAGAN
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 1:936 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3014
Mailing Address - Country:US
Mailing Address - Phone:217-243-1728
Mailing Address - Fax:217-243-8380
Practice Address - Street 1:936 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3014
Practice Address - Country:US
Practice Address - Phone:217-243-1728
Practice Address - Fax:217-143-8380
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051287907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051287907Other051287907
IL051287907OtherSTATE OF ILLINOIS