Healthcare Provider Details

I. General information

NPI: 1407762289
Provider Name (Legal Business Name): TRAVIS EUGENE WILSON CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 6TH ST
BROOKLYN NY
11215-3609
US

IV. Provider business mailing address

502 W 135TH ST APT 1C
NEW YORK NY
10031-8643
US

V. Phone/Fax

Practice location:
  • Phone: 646-584-8379
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number001642
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: