Provider Demographics
NPI:1447880760
Name:SPARKMAM, TRACY C (PHARM D)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:C
Last Name:SPARKMAM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:SHEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:3930 44TH AVENUE DR STOP 1
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3893
Mailing Address - Country:US
Mailing Address - Phone:309-736-2275
Mailing Address - Fax:
Practice Address - Street 1:3930 44TH AVENUE DR STOP 1
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3893
Practice Address - Country:US
Practice Address - Phone:309-736-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-26
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051298104183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist