Healthcare Provider Details

I. General information

NPI: 1124491840
Provider Name (Legal Business Name): TRAVIS OBANNON PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9820 CALLABRIDGE CT
CHARLOTTE NC
28216-7669
US

IV. Provider business mailing address

3547 SPENCER ST
CHARLOTTE NC
28205-1243
US

V. Phone/Fax

Practice location:
  • Phone: 704-392-3131
  • Fax:
Mailing address:
  • Phone: 757-202-4926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24716
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: