Provider Demographics
NPI:1073619201
Name:TRAVELMART INC.
Entity Type:Organization
Organization Name:TRAVELMART INC.
Other - Org Name:TRAVELMART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-253-4231
Mailing Address - Street 1:802 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965
Mailing Address - Country:US
Mailing Address - Phone:608-253-4231
Mailing Address - Fax:608-253-7317
Practice Address - Street 1:802 BROADWAY
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965
Practice Address - Country:US
Practice Address - Phone:608-253-4231
Practice Address - Fax:608-253-7317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7305-0423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33191600Medicaid
WI33191600Medicaid
WI0919410001Medicare ID - Type Unspecified