Provider Demographics
NPI:1144566894
Name:WALTHALL, TRAVIS (RPH)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WALTHALL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 W 4TH ST
Mailing Address - Street 2:PO BOX 246
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-2046
Mailing Address - Country:US
Mailing Address - Phone:208-922-4400
Mailing Address - Fax:208-922-4499
Practice Address - Street 1:173 W 4TH ST
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-2046
Practice Address - Country:US
Practice Address - Phone:208-922-4400
Practice Address - Fax:208-922-4499
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5435183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist