MEDICARE: TRAVIS JAMES MACFARLANE

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	5302412727	MI

General Provider Information

NPI Number	:	1588272553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS JAMES MACFARLANE

Provider Business Mailing Address
First Line	:	5302 N LAKE SHORE DR
Second Line	:
City	:	BLACK RIVER
State	:	MI
Zip	:	48721-9705
Country	:	US
Telephone Number	:	586-994-1210
Fax Number	:

Provider Business Practice Location Address
First Line	:	1231 E BELTLINE AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-4501
Country	:	US
Telephone Number	:	616-575-5438
Fax Number	:

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

Provider Enumeration Date	:	07/16/2020
Last Update Date	:	08/24/2021

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