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General NPI Number Information
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NPI Number | 1457969594
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Entity Type | Individual
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Provider Name | TRAVIS OMMODT
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Gender | Male
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Dates
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Enumeration Date | 07/15/2020
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Last Update Date | 07/15/2020
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Provider Practice Location Address
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Address Line | 3360 TITTABAWASSEE RD
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City | SAGINAW
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State | MI
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Zip | 48604-9453
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Country | US
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Telephone | 989-249-6010
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Fax | 989-249-6065
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Provider Business Mailing Address
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Address Line | 3519 VAN HORN RD
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City | JACKSON
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State | MI
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Zip | 49201-9442
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Country | US
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Telephone | 517-745-9082
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835P1200X
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Taxonomy Name | Pharmacotherapy Pharmacist
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License Number | 5302412614
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License Number State | MI
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