Provider Demographics
NPI:1508164997
Name:TRAVIS, PRISCILLA BOLT (DPH)
Entity Type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:BOLT
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:956 EVERETT DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6217
Mailing Address - Country:US
Mailing Address - Phone:615-459-3925
Mailing Address - Fax:
Practice Address - Street 1:5192 MURFREESBORO ROAD
Practice Address - Street 2:RITE AID PHARMACY
Practice Address - City:LAVERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086
Practice Address - Country:US
Practice Address - Phone:615-213-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist