Provider Demographics
NPI:1790808871
Name:DAVIS, TRAVIS M
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12204 LAKE FERN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5367
Mailing Address - Country:US
Mailing Address - Phone:904-403-7313
Mailing Address - Fax:
Practice Address - Street 1:12204 LAKE FERN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5367
Practice Address - Country:US
Practice Address - Phone:904-403-7313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31071183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist