Provider Demographics
NPI:1992173512
Name:POWERS, TRACI S (PHARMD)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:S
Last Name:POWERS
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 1:538 S EADDY FORD RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29555-5201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3320 4TH AVE STE F
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29527-6057
Practice Address - Country:US
Practice Address - Phone:843-248-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC71399DMedicaid