Provider Demographics
NPI:1366150880
Name:SPANGENBERG, TRACEY JANE (RPH)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:JANE
Last Name:SPANGENBERG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:JANE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:9300 CAMPUS POINT
Mailing Address - Street 2:DEPT PHARMACY
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7727
Mailing Address - Country:US
Mailing Address - Phone:858-657-5006
Mailing Address - Fax:
Practice Address - Street 1:9300 CAMPUS POINT
Practice Address - Street 2:DEPT PHARMACY
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7727
Practice Address - Country:US
Practice Address - Phone:858-657-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist