Healthcare Provider Details

I. General information

NPI: 1639618093
Provider Name (Legal Business Name): TRAVIS STARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5224 COLDWATER CANYON AVE
VAN NUYS CA
91401-6146
US

IV. Provider business mailing address

5224 COLDWATER CANYON AVE
VAN NUYS CA
91401-6146
US

V. Phone/Fax

Practice location:
  • Phone: 818-487-2715
  • Fax: 818-487-7364
Mailing address:
  • Phone: 818-487-2715
  • Fax: 818-487-7364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number59242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: