Provider Demographics
NPI:1447880083
Name:HUNTER, TRAVIS LESLIE
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LESLIE
Last Name:HUNTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-2919
Mailing Address - Country:US
Mailing Address - Phone:712-542-6546
Mailing Address - Fax:712-542-4955
Practice Address - Street 1:1200 S 16TH ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2919
Practice Address - Country:US
Practice Address - Phone:712-542-6546
Practice Address - Fax:712-542-4955
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19126183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist