Provider Demographics
NPI:1508590555
Name:HARRIS, TRAVIS LEE (RPH)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:LEE
Last Name:HARRIS
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 1:11217 STATE ROUTE 41
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45693-9397
Mailing Address - Country:US
Mailing Address - Phone:937-544-7291
Mailing Address - Fax:937-544-4913
Practice Address - Street 1:11217 STATE ROUTE 41
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:OH
Practice Address - Zip Code:45693-9397
Practice Address - Country:US
Practice Address - Phone:937-544-7291
Practice Address - Fax:937-544-4913
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03442046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03442046Medicaid