Provider Demographics
NPI:1104567114
Name:TRACEY, KEVIN ONEAL
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ONEAL
Last Name:TRACEY
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 1:12459 NW 17TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1893
Mailing Address - Country:US
Mailing Address - Phone:954-861-9164
Mailing Address - Fax:
Practice Address - Street 1:14375 MIRAMAR PKWY
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-4134
Practice Address - Country:US
Practice Address - Phone:954-447-9212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS63017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist