Provider Demographics
NPI:1922604636
Name:TICHENOR, TRAVIS DAVID JR
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DAVID
Last Name:TICHENOR
Suffix:JR
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 1:604 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75494-3230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:604 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3230
Practice Address - Country:US
Practice Address - Phone:903-342-5217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18466183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist