Provider Demographics
NPI:1588964647
Name:BOTTOMLEY, TRACY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:BOTTOMLEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6774 GLADE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ENNICE
Mailing Address - State:NC
Mailing Address - Zip Code:28623-9142
Mailing Address - Country:US
Mailing Address - Phone:336-657-8347
Mailing Address - Fax:
Practice Address - Street 1:1395 W D ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3505
Practice Address - Country:US
Practice Address - Phone:336-651-2910
Practice Address - Fax:336-651-2907
Is Sole Proprietor?:No
Enumeration Date:2010-10-23
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist