Provider Demographics
NPI:1568458719
Name:PETTINGER, TRACY K (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:K
Last Name:PETTINGER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:IDAHO STATE UNIVERSITY
Mailing Address - Street 2:CAMPUS BOX 8357
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0001
Mailing Address - Country:US
Mailing Address - Phone:208-282-5012
Mailing Address - Fax:
Practice Address - Street 1:465 MEMORIAL DR
Practice Address - Street 2:IDAHO STATE UNIVERSITY
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4008
Practice Address - Country:US
Practice Address - Phone:208-282-5012
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP57431835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy