Provider Demographics
NPI:1992963938
Name:MEDINA, DAWN TRACEY (RPH)
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:TRACEY
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6125 SAMUEL RD
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6301
Mailing Address - Country:US
Mailing Address - Phone:301-865-4736
Mailing Address - Fax:301-865-4736
Practice Address - Street 1:12817 SHANK FARM WAY
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-665-9568
Practice Address - Fax:301-665-9798
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist