Healthcare Provider Details

I. General information

NPI: 1154938082
Provider Name (Legal Business Name): TRAVIS EZELL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 MICHAELA DR
NORTH LITTLE ROCK AR
72117-5361
US

IV. Provider business mailing address

1101 TROY DR
BENTON AR
72019-1904
US

V. Phone/Fax

Practice location:
  • Phone: 501-992-1006
  • Fax:
Mailing address:
  • Phone: 870-405-7041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD14976
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: