Healthcare Provider Details

I. General information

NPI: 1962910448
Provider Name (Legal Business Name): TRACY LYNN O'DONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5581 MERCHANTS VIEW SQ
HAYMARKET VA
20169-5439
US

IV. Provider business mailing address

5581 MERCHANTS VIEW SQ
HAYMARKET VA
20169-5439
US

V. Phone/Fax

Practice location:
  • Phone: 703-581-8757
  • Fax: 717-960-8398
Mailing address:
  • Phone: 703-581-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202012967
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0202012967
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: