Provider Demographics
NPI:1356483184
Name:KENNEDY, TRAVIS J (PHARMD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:KENNEDY
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 1:1017 KING PLACE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-2635
Mailing Address - Country:US
Mailing Address - Phone:706-653-9648
Mailing Address - Fax:
Practice Address - Street 1:710 CENTER STREET
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901
Practice Address - Country:US
Practice Address - Phone:706-571-1396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist