Healthcare Provider Details

I. General information

NPI: 1063163541
Provider Name (Legal Business Name): TRACY MUDALUE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 34TH ST STE 200
BAKERSFIELD CA
93301-2307
US

IV. Provider business mailing address

625 34TH ST STE 200
BAKERSFIELD CA
93301-2307
US

V. Phone/Fax

Practice location:
  • Phone: 833-678-2781
  • Fax: 661-368-0618
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number85560
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: