=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518235753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRAVIS WHITESIDE PHARM.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2011
-----------------------------------------------------
Last Update Date | 05/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3551 ROGER BROOKE DR DEPT OF PHARMACY, BROOKE ARMY MEDICAL CENTER (BAMC)
-----------------------------------------------------
City | FT. SAM HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-916-7633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2747 ARTILLERY POST RD UNIT C
-----------------------------------------------------
City | FORT SAM HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78234-2682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-329-8275
-----------------------------------------------------
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 | 16737
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------