Provider Demographics
NPI:1861114043
Name:MOCK, TRACEE ELIZABETH (PHARMD)
Entity type:Individual
Prefix:
First Name:TRACEE
Middle Name:ELIZABETH
Last Name:MOCK
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 1:3826 SE BELLE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-9214
Mailing Address - Country:US
Mailing Address - Phone:503-207-8058
Mailing Address - Fax:
Practice Address - Street 1:1001 N PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7485
Practice Address - Country:US
Practice Address - Phone:503-537-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0019045183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist