Healthcare Provider Details

I. General information

NPI: 1649874751
Provider Name (Legal Business Name): TRAVIS A KNUDSEN PHARMACIST INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S ORANGE BLOSSOM TRL
APOPKA FL
32703-7603
US

IV. Provider business mailing address

1500 S ORANGE BLOSSOM TRL
APOPKA FL
32703-7603
US

V. Phone/Fax

Practice location:
  • Phone: 407-553-4108
  • Fax:
Mailing address:
  • Phone: 407-553-4108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPSI39341
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPSI39341
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: