Provider Demographics
NPI:1255980660
Name:PETERS, TRAVIS GLENN (PHARMD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:GLENN
Last Name:PETERS
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 1:762 OSBORNE LN
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-7522
Mailing Address - Country:US
Mailing Address - Phone:502-663-3287
Mailing Address - Fax:
Practice Address - Street 1:420 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HANSON
Practice Address - State:KY
Practice Address - Zip Code:42413-9499
Practice Address - Country:US
Practice Address - Phone:270-821-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028360A1835P2201X
KY0208171835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care