Provider Demographics
NPI:1124041082
Name:CORK, TRAVIS J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:J
Last Name:CORK
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 1:711 SAMUEL LN
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4434
Mailing Address - Country:US
Mailing Address - Phone:307-399-0881
Mailing Address - Fax:
Practice Address - Street 1:711 SAMUEL LN
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4434
Practice Address - Country:US
Practice Address - Phone:307-399-0881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY31221835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy