Provider Demographics
NPI:1235515156
Name:CUNNINGHAM, TRAVIS (PHARMD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:CUNNINGHAM
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 1:175 W WHISKEY RUN RD NE
Mailing Address - Street 2:
Mailing Address - City:NEW SALISBURY
Mailing Address - State:IN
Mailing Address - Zip Code:47161-8804
Mailing Address - Country:US
Mailing Address - Phone:502-298-3627
Mailing Address - Fax:
Practice Address - Street 1:3036 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3020
Practice Address - Country:US
Practice Address - Phone:502-458-2647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017979183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist