Provider Demographics
NPI:1417295882
Name:SKULLY, SCOTT ROBERT
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ROBERT
Last Name:SKULLY
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 1:2420 SANTA BARBARA BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-4485
Mailing Address - Country:US
Mailing Address - Phone:239-574-7987
Mailing Address - Fax:239-574-8120
Practice Address - Street 1:2420 SANTA BARBARA BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-4485
Practice Address - Country:US
Practice Address - Phone:239-574-7987
Practice Address - Fax:239-574-8120
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-19
Last Update Date:2013-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS49089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist