Provider Demographics
NPI:1417206962
Name:FORWARD, TRACY WILLIAM (RPH)
Entity type:Individual
Prefix:MR
First Name:TRACY
Middle Name:WILLIAM
Last Name:FORWARD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CASA LOMA RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9435
Mailing Address - Country:US
Mailing Address - Phone:505-239-4930
Mailing Address - Fax:
Practice Address - Street 1:9640 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2217
Practice Address - Country:US
Practice Address - Phone:505-294-4167
Practice Address - Fax:505-294-5229
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist