MEDICARE: TRACEY LANESEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	054504	NY
2	183500000X	Pharmacist	054504-1	NY

General Provider Information

NPI Number	:	1790074599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY LANESEY

Provider Business Mailing Address
First Line	:	PO BOX 1000
Second Line	:	MS3000
City	:	PORTLAND
State	:	ME
Zip	:	04104-5005
Country	:	US
Telephone Number	:	207-885-7454
Fax Number	:	207-396-2028

Provider Business Practice Location Address
First Line	:	43 ROUND LAKE RD
Second Line	:
City	:	BALLSTON LAKE
State	:	NY
Zip	:	12019-1147
Country	:	US
Telephone Number	:	518-899-2748
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2011
Last Update Date	:	05/19/2021

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Directions to “ TRACEY LANESEY ” Practice Location

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