Provider Demographics
NPI:1033329248
Name:PARK, TRAVIS ANTHONY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:ANTHONY
Last Name:PARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 E PINE HILL DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-6618
Mailing Address - Country:US
Mailing Address - Phone:208-169-3128
Mailing Address - Fax:
Practice Address - Street 1:2003 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2611
Practice Address - Country:US
Practice Address - Phone:208-666-3032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist