Healthcare Provider Details

I. General information

NPI: 1700109873
Provider Name (Legal Business Name): TRACY LYN ANONICH R.PH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N ROCHESTER ST
MUKWONAGO WI
53149-1142
US

IV. Provider business mailing address

S93W33534 FIELDSIDE CT
MUKWONAGO WI
53149-8202
US

V. Phone/Fax

Practice location:
  • Phone: 262-363-4001
  • Fax:
Mailing address:
  • Phone: 262-594-3023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11539
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: