Provider Demographics
NPI:1306564646
Name:ADDISON, TRACY LYNN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:ADDISON
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 1:1145 WALDRON RD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418-2610
Mailing Address - Country:US
Mailing Address - Phone:361-939-5555
Mailing Address - Fax:866-500-8848
Practice Address - Street 1:1145 WALDRON RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78418-2610
Practice Address - Country:US
Practice Address - Phone:361-939-5555
Practice Address - Fax:866-500-8848
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician