MEDICARE: MR. TRAVIS G MAINOUS RPH.

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	183500000X	Pharmacist	26021257A	IN

General Provider Information

NPI Number	:	1538705991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRAVIS G MAINOUS RPH.

Provider Business Mailing Address
First Line	:	6420 BETHEL RD
Second Line	:
City	:	FOUNTAIN CITY
State	:	IN
Zip	:	47341-9791
Country	:	US
Telephone Number	:	513-255-0484
Fax Number	:

Provider Business Practice Location Address
First Line	:	3701 NATIONAL RD E
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-3614
Country	:	US
Telephone Number	:	765-935-2074
Fax Number	:	765-962-3049

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

Provider Enumeration Date	:	11/20/2019
Last Update Date	:	11/20/2019

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