Provider Demographics
NPI:1902135759
Name:ORTEGA, TRACEY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:
Last Name:ORTEGA
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 1:504 HIGHWAY 71 W
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-3735
Mailing Address - Country:US
Mailing Address - Phone:512-321-4008
Mailing Address - Fax:
Practice Address - Street 1:504 HIGHWAY 71 W
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3735
Practice Address - Country:US
Practice Address - Phone:512-321-4008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45490183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist