Provider Demographics
NPI:1386245843
Name:GOODWILL, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:GOODWILL
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 1:7575 LINTON HALL RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-2971
Mailing Address - Country:US
Mailing Address - Phone:703-754-2357
Mailing Address - Fax:
Practice Address - Street 1:7575 LINTON HALL RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-2971
Practice Address - Country:US
Practice Address - Phone:703-754-2357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist