Provider Demographics
NPI:1215910229
Name:BIDEGANETA, TRACY LYNN (RPH)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:BIDEGANETA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:CANTRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:270 N 2ND E
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2725
Mailing Address - Country:US
Mailing Address - Phone:208-587-2368
Mailing Address - Fax:208-587-2052
Practice Address - Street 1:270 N 2ND E
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2725
Practice Address - Country:US
Practice Address - Phone:208-587-3346
Practice Address - Fax:208-587-2052
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist