Provider Demographics
NPI:1164497608
Name:SORENSEN, SCOTT EDWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:EDWARD
Last Name:SORENSEN
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 1:1221 HILLCREST AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2626
Mailing Address - Country:US
Mailing Address - Phone:616-791-9949
Mailing Address - Fax:
Practice Address - Street 1:1965 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8915
Practice Address - Country:US
Practice Address - Phone:616-457-9630
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025308183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist