Provider Demographics
NPI:1831792472
Name:TRAVIS, ANTHONY WAYNE (PHARMD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WAYNE
Last Name:TRAVIS
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 1:104 SONOMA LN
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-1410
Mailing Address - Country:US
Mailing Address - Phone:423-902-7144
Mailing Address - Fax:
Practice Address - Street 1:3040 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4004
Practice Address - Country:US
Practice Address - Phone:706-861-6252
Practice Address - Fax:706-861-5917
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH015043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist