Provider Demographics
NPI:1275994170
Name:NELSON, SCOTT RYAN
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RYAN
Last Name:NELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WEST ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-2640
Mailing Address - Country:US
Mailing Address - Phone:203-888-9068
Mailing Address - Fax:203-888-7677
Practice Address - Street 1:215 WEST ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:CT
Practice Address - Zip Code:06483-2640
Practice Address - Country:US
Practice Address - Phone:203-888-9068
Practice Address - Fax:203-888-7677
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2016-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0012093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist