Healthcare Provider Details

I. General information

NPI: 1003091869
Provider Name (Legal Business Name): TRACY ANN TOWNE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2007
Last Update Date: 12/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 N MAIN ST
GLOVERSVILLE NY
12078-2402
US

IV. Provider business mailing address

169 N MAIN ST
GLOVERSVILLE NY
12078-2402
US

V. Phone/Fax

Practice location:
  • Phone: 518-725-8659
  • Fax: 518-725-9757
Mailing address:
  • Phone: 518-725-8659
  • Fax: 518-725-9757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number044900-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: