Provider Demographics
NPI:1992928097
Name:CLARK, TRACY M (CPHT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 E OATES RD APT 101
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-3454
Mailing Address - Country:US
Mailing Address - Phone:469-648-8444
Mailing Address - Fax:
Practice Address - Street 1:3409 WORTH ST
Practice Address - Street 2:725
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2029
Practice Address - Country:US
Practice Address - Phone:214-276-5616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119588183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119588OtherTEXAS STATE BOARD OF PHARMACY
TX170109717629639OtherPHARMACY TECHNICIAN CERTIFICATION BOARD