Provider Demographics
NPI:1861795338
Name:MATHENA, TRACY LYNN (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:MATHENA
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:US RT 52 N
Mailing Address - Street 2:
Mailing Address - City:BLUEWELL
Mailing Address - State:WV
Mailing Address - Zip Code:24701
Mailing Address - Country:US
Mailing Address - Phone:304-589-7732
Mailing Address - Fax:304-589-7843
Practice Address - Street 1:US RT 52 N
Practice Address - Street 2:
Practice Address - City:BLUEWELL
Practice Address - State:WV
Practice Address - Zip Code:24701
Practice Address - Country:US
Practice Address - Phone:304-589-7732
Practice Address - Fax:304-589-7843
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007220183500000X
VA0202208337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist