Provider Demographics
NPI:1649611054
Name:MOONEYHAM, TRACY DON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:DON
Last Name:MOONEYHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 W NETTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3970
Mailing Address - Country:US
Mailing Address - Phone:870-932-4742
Mailing Address - Fax:870-932-0311
Practice Address - Street 1:619 W NETTLETON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3970
Practice Address - Country:US
Practice Address - Phone:870-932-4742
Practice Address - Fax:870-932-0311
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-13
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD12355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist