MEDICARE: MRS. TRACEY V. GOYTIA PHARMD, RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051-287599	IL
2	133V00000X	Registered Dietitian	164000923	IL

General Provider Information

NPI Number	:	1053434340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACEY V. GOYTIA PHARMD, RD

Provider Business Mailing Address
First Line	:	468 NORMAN CT
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60016-2443
Country	:	US
Telephone Number	:	847-734-0902
Fax Number	:

Provider Business Practice Location Address
First Line	:	1555 LEE ST
Second Line	:
City	:	DES PLAINES
State	:	IL
Zip	:	60018-1518
Country	:	US
Telephone Number	:	847-299-4488
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	11/01/2010

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