Healthcare Provider Details

I. General information

NPI: 1043429707
Provider Name (Legal Business Name): TRACY BETH HEAD PHARMD, CGP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 S. MAIN STREET
DEFOREST WI
53532
US

IV. Provider business mailing address

643 S. MAIN STREET
DEFOREST WI
53532
US

V. Phone/Fax

Practice location:
  • Phone: 608-846-2750
  • Fax: 608-846-2751
Mailing address:
  • Phone: 608-846-2750
  • Fax: 608-846-2751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14709-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: