Provider Demographics
NPI:1124317607
Name:ANDERSON, TRAVIS L (RPH)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 BUCKHANNON PIKE
Mailing Address - Street 2:
Mailing Address - City:NUTTER FORT
Mailing Address - State:WV
Mailing Address - Zip Code:26301-4307
Mailing Address - Country:US
Mailing Address - Phone:304-622-6315
Mailing Address - Fax:304-622-6337
Practice Address - Street 1:829 N LOOP 340 STE A
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-2592
Practice Address - Country:US
Practice Address - Phone:254-202-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18258183500000X
TX60409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist