Provider Demographics
NPI:1962910448
Name:O'DONNELL, TRACY LYNN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:O'DONNELL
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 1:5581 MERCHANTS VIEW SQ
Mailing Address - Street 2:
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-5439
Mailing Address - Country:US
Mailing Address - Phone:703-581-8757
Mailing Address - Fax:
Practice Address - Street 1:5581 MERCHANTS VIEW SQ
Practice Address - Street 2:
Practice Address - City:HAYMARKET
Practice Address - State:VA
Practice Address - Zip Code:20169-5439
Practice Address - Country:US
Practice Address - Phone:703-581-8757
Practice Address - Fax:717-960-8398
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02020129671835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010328471Medicaid