Provider Demographics
NPI:1194132316
Name:TRAVIS, VICTORIA LYNN
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4096 PIEDMONT AVE UNIT 544
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5221
Mailing Address - Country:US
Mailing Address - Phone:626-354-5942
Mailing Address - Fax:
Practice Address - Street 1:1131 W FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:RIO RICO
Practice Address - State:AZ
Practice Address - Zip Code:85648
Practice Address - Country:US
Practice Address - Phone:520-761-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZI010188183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist