Provider Demographics
NPI:1528302643
Name:WHITE, TRAVIS GRANT (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:GRANT
Last Name:WHITE
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 1:1124 HSC NORTH PO BOX 9520
Mailing Address - Street 2:WVU SCHOOL OF PHARMACY
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506
Mailing Address - Country:US
Mailing Address - Phone:304-293-0681
Mailing Address - Fax:
Practice Address - Street 1:1124 HSC NORTH
Practice Address - Street 2:WVU SCHOOL OF PHARMACY
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-293-0681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist