Provider Demographics
NPI:1437704004
Name:TRAVIS, LORI JEFFERSON
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:JEFFERSON
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 HENNESSY BLVD STE 114
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4363
Mailing Address - Country:US
Mailing Address - Phone:225-765-8951
Mailing Address - Fax:225-765-3472
Practice Address - Street 1:7777 HENNESSY BLVD STE 114
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4363
Practice Address - Country:US
Practice Address - Phone:225-765-8951
Practice Address - Fax:225-765-3472
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16873183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist