Provider Demographics
NPI:1942809983
Name:TATE, GRACIE NICOLE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:GRACIE
Middle Name:NICOLE
Last Name:TATE
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 1:45 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-2034
Mailing Address - Country:US
Mailing Address - Phone:618-833-4521
Mailing Address - Fax:
Practice Address - Street 1:45 PLAZA DR
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-2034
Practice Address - Country:US
Practice Address - Phone:618-833-4521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.3033671835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist