Provider Demographics
NPI:1861096166
Name:KOTECKI, TRACY LOUISE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LOUISE
Last Name:KOTECKI
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 1:1004 SHOOTING PARK RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1871
Mailing Address - Country:US
Mailing Address - Phone:815-224-1411
Mailing Address - Fax:
Practice Address - Street 1:1004 SHOOTING PARK RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1871
Practice Address - Country:US
Practice Address - Phone:815-224-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.286680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist