Provider Demographics
NPI:1922442185
Name:ANDERSON, TRACY NICOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:NICOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-3025
Mailing Address - Country:US
Mailing Address - Phone:347-419-7767
Mailing Address - Fax:
Practice Address - Street 1:270 S SERVICE RD STE 25
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2399
Practice Address - Country:US
Practice Address - Phone:631-237-8594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65200183500000X
NY072254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist