Provider Demographics
NPI:1548374424
Name:HALE-SMITH, TRACIE LYNN
Entity type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:LYNN
Last Name:HALE-SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 FAIRWAYS DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8304
Mailing Address - Country:US
Mailing Address - Phone:601-636-5822
Mailing Address - Fax:
Practice Address - Street 1:1123 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2959
Practice Address - Country:US
Practice Address - Phone:601-636-2756
Practice Address - Fax:601-638-0071
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE07658183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE07658OtherSTATE LICENSE