Provider Demographics
NPI:1487372892
Name:TRACEY, PATRICK JASON JR (PHARM D)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:JASON
Last Name:TRACEY
Suffix:JR
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 TIOGUE AVE
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-5805
Mailing Address - Country:US
Mailing Address - Phone:401-821-2060
Mailing Address - Fax:
Practice Address - Street 1:763 TIOGUE AVE
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-5805
Practice Address - Country:US
Practice Address - Phone:401-821-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH06428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist