=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144595968
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRAVIS C JACKMAN PHARM D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2012
-----------------------------------------------------
Last Update Date | 12/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 E RIVERSIDE DR STE 104
-----------------------------------------------------
City | ST GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84790-8720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-656-2059
-----------------------------------------------------
Fax | 435-656-3059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1508 BOYS POND CIR
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84765-5736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 4911172-1701
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------