Healthcare Provider Details

I. General information

NPI: 1063415743
Provider Name (Legal Business Name): TRAVIS EDWARD WATTS PHARM.D., CDE, BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 NW 56TH ST 5 CORPORATE PLAZA
OKLAHOMA CITY OK
73112-4519
US

IV. Provider business mailing address

1200 OUTABOUNDS DR
EDMOND OK
73034-3079
US

V. Phone/Fax

Practice location:
  • Phone: 405-951-3829
  • Fax: 405-951-3916
Mailing address:
  • Phone: 405-285-8766
  • Fax: 405-951-3916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number11493
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: