Provider Demographics
NPI:1144595968
Name:JACKMAN, TRAVIS C (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:C
Last Name:JACKMAN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 BOYS POND CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:UT
Mailing Address - Zip Code:84765-5736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:617 E RIVERSIDE DR STE 104
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8720
Practice Address - Country:US
Practice Address - Phone:435-656-2059
Practice Address - Fax:435-656-3059
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4911172-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist