Provider Demographics
NPI:1366085060
Name:EDDLEMON, TRAVIS LOGAN (RPH)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LOGAN
Last Name:EDDLEMON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3842
Mailing Address - Country:US
Mailing Address - Phone:318-445-6386
Mailing Address - Fax:
Practice Address - Street 1:3333 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3842
Practice Address - Country:US
Practice Address - Phone:318-623-6992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist