Provider Demographics
NPI:1437286200
Name:CORCORAN, SCOTT E
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:E
Last Name:CORCORAN
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 1:8406 CHERRY VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-2120
Mailing Address - Country:US
Mailing Address - Phone:703-373-3097
Mailing Address - Fax:
Practice Address - Street 1:110 LUKE AVE
Practice Address - Street 2:ROOM 400, HQ USAF SG8X
Practice Address - City:BOLLING AIR FORCE BASE
Practice Address - State:DC
Practice Address - Zip Code:20032-7050
Practice Address - Country:US
Practice Address - Phone:202-767-0297
Practice Address - Fax:202-767-5053
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist