Provider Demographics
NPI:1255732970
Name:COFFEY, TRAVIS (PHARMD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:COFFEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-1857
Mailing Address - Country:US
Mailing Address - Phone:904-819-6774
Mailing Address - Fax:
Practice Address - Street 1:955 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-1857
Practice Address - Country:US
Practice Address - Phone:904-819-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist