Provider Demographics
NPI:1154938082
Name:EZELL, TRAVIS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:
Last Name:EZELL
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 1:1101 TROY DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-1904
Mailing Address - Country:US
Mailing Address - Phone:870-405-7041
Mailing Address - Fax:
Practice Address - Street 1:760 MICHAELA DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-5361
Practice Address - Country:US
Practice Address - Phone:501-992-1006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14976183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist