Provider Demographics
NPI:1457969594
Name:OMMODT, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:OMMODT
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 1:3519 VAN HORN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9442
Mailing Address - Country:US
Mailing Address - Phone:517-745-9082
Mailing Address - Fax:
Practice Address - Street 1:3360 TITTABAWASSEE RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9453
Practice Address - Country:US
Practice Address - Phone:989-249-6010
Practice Address - Fax:989-249-6065
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53024126141835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy