MEDICARE: TRAVIS GANNON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302412978	MI

General Provider Information

NPI Number	:	1225632599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS GANNON

Provider Business Mailing Address
First Line	:	17433 DUVAL CT
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-7127
Country	:	US
Telephone Number	:	586-353-1151
Fax Number	:

Provider Business Practice Location Address
First Line	:	8200 26 MILE RD
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-5132
Country	:	US
Telephone Number	:	586-677-5084
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2020
Last Update Date	:	11/26/2020

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