Provider Demographics
NPI:1033992375
Name:ISRINGHAUSEN, TREVOR T
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:T
Last Name:ISRINGHAUSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 E BROADWAY STE 118
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5896
Mailing Address - Country:US
Mailing Address - Phone:573-449-5366
Mailing Address - Fax:573-443-7938
Practice Address - Street 1:1506 E BROADWAY STE 118
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5896
Practice Address - Country:US
Practice Address - Phone:573-449-5366
Practice Address - Fax:573-443-7938
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014026875183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist