Provider Demographics
NPI:1861877276
Name:POWELL, TRACY (RPH)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:SHEPARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:605 MCCLELLAN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-1308
Mailing Address - Country:US
Mailing Address - Phone:913-364-5156
Mailing Address - Fax:
Practice Address - Street 1:5000 S 13TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5581
Practice Address - Country:US
Practice Address - Phone:913-290-7257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18162183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist