Basic Information
| Provider Information | |||||||||
| NPI: | 1922444041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.PH. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZERBY | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.PH. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1401 GALAXY DR NE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985164746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604567862 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1401 GALAXY DR NE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985164746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604567862 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2013 | ||||||||
| LastUpdateDate: | 07/21/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH00018024 | WA | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 2026868 | 05 | WA | MEDICAID |