Provider Demographics
NPI:1215236591
Name:TRACY, ANGELA (RPH)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:TRACY
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 1:720 WINDING OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 ORMSBY STATION CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4039
Practice Address - Country:US
Practice Address - Phone:502-558-8571
Practice Address - Fax:502-423-4176
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293267183500000X
TN33510183500000X
KY10176183500000X
KY0101761835P0018X
IN26023088A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist