Provider Demographics
NPI:1477184042
Name:TRAVIS, JOHN (PHARMACIST)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41866 RAVENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3926
Mailing Address - Country:US
Mailing Address - Phone:313-303-5084
Mailing Address - Fax:
Practice Address - Street 1:1625 KING RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-1259
Practice Address - Country:US
Practice Address - Phone:734-671-4302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302047253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist