MEDICARE: NOUR TRAVIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	5302047344	MI

General Provider Information

NPI Number	:	1184271827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NOUR TRAVIS

Provider Business Mailing Address
First Line	:	PO BOX 1018
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48121-1018
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9000 E JEFFERSON AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48214-4188
Country	:	US
Telephone Number	:	313-269-2444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2019
Last Update Date	:	08/19/2019

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Directions to “ NOUR TRAVIS ” Practice Location

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