=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376670133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY MARIE MULKIN RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 945 FAIRMOUNT AVE
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14701-2454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-483-9909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9044 FREDONIA STOCKTON RD
-----------------------------------------------------
City | FREDONIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14063-9693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-673-9232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 048577
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 24381
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------