Provider Demographics
NPI:1699153932
Name:GAINES, TRACEY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:
Last Name:GAINES
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 1:2801 W DAUPHIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-4641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 W DAUPHIN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-4641
Practice Address - Country:US
Practice Address - Phone:215-225-1912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRP448914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist