Provider Demographics
NPI:1336404490
Name:LACORE, TRAVIS OWEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:OWEN
Last Name:LACORE
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:P.O. BOX 357
Mailing Address - Street 2:113 NORTH 3RD STREET
Mailing Address - City:KIESTER
Mailing Address - State:MN
Mailing Address - Zip Code:56051
Mailing Address - Country:US
Mailing Address - Phone:507-459-8421
Mailing Address - Fax:641-298-1204
Practice Address - Street 1:113 NORTH 3RD STREET
Practice Address - Street 2:
Practice Address - City:KIESTER
Practice Address - State:MN
Practice Address - Zip Code:56051
Practice Address - Country:US
Practice Address - Phone:507-459-8421
Practice Address - Fax:641-298-1204
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118237183500000X
IA21210183500000X
SD5416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist