Provider Demographics
NPI:1538705991
Name:MAINOUS, TRAVIS G (RPH)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:G
Last Name:MAINOUS
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 1:6420 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47341-9791
Mailing Address - Country:US
Mailing Address - Phone:513-255-0484
Mailing Address - Fax:
Practice Address - Street 1:3701 NATIONAL RD E
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-3614
Practice Address - Country:US
Practice Address - Phone:765-935-2074
Practice Address - Fax:765-962-3049
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021257A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist