Basic Information
| Provider Information | |||||||||
| NPI: | 1538175302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 W HIGH ST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458012969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192277399 | ||||||||
| FaxNumber: | 4192259610 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 W HIGH ST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458012969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192277399 | ||||||||
| FaxNumber: | 4192259610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 03-3-19931 | OH | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.