Provider Demographics
NPI:1124195458
Name:SCOTT, SANDRA GRACE (PHT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:GRACE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5807 NORTHGATE DR.
Mailing Address - Street 2:
Mailing Address - City:SATSUMA
Mailing Address - State:AL
Mailing Address - Zip Code:36572
Mailing Address - Country:US
Mailing Address - Phone:251-679-8636
Mailing Address - Fax:
Practice Address - Street 1:5565 HWY 43
Practice Address - Street 2:
Practice Address - City:SATSUMA
Practice Address - State:AL
Practice Address - Zip Code:36572
Practice Address - Country:US
Practice Address - Phone:251-675-2070
Practice Address - Fax:251-675-7785
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALT14115183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician