Healthcare Provider Details

I. General information

NPI: 1215236591
Provider Name (Legal Business Name): ANGELA TRACY RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 ORMSBY STATION CT
LOUISVILLE KY
40223-4039
US

IV. Provider business mailing address

720 WINDING OAKS TRL
LOUISVILLE KY
40223-2300
US

V. Phone/Fax

Practice location:
  • Phone: 502-558-8571
  • Fax: 502-423-4176
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.293267
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number33510
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10176
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number010176
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26023088A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: