Provider Demographics
NPI:1063660728
Name:SCOTT, EDWIN GRANT JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:GRANT
Last Name:SCOTT
Suffix:JR
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 1:955 S. SECOND ST.
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740
Mailing Address - Country:US
Mailing Address - Phone:575-445-3131
Mailing Address - Fax:575-445-5393
Practice Address - Street 1:955 S. SECOND ST.
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740
Practice Address - Country:US
Practice Address - Phone:575-445-3131
Practice Address - Fax:575-445-5393
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist