Provider Demographics
NPI:1982092458
Name:MATTIA, TRACY (PHARM D)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:MATTIA
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11310 SE US HWY 301
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420
Mailing Address - Country:US
Mailing Address - Phone:352-245-6522
Mailing Address - Fax:352-245-5801
Practice Address - Street 1:11310 SE US HWY 301
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420
Practice Address - Country:US
Practice Address - Phone:352-245-6522
Practice Address - Fax:352-245-5801
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist