Provider Demographics
NPI:1558656470
Name:DECESARE, SCOTT R (RPH)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:DECESARE
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 1:1075 KENNEDY RD
Mailing Address - Street 2:TARGET PHARMACY STORE NUMBER (T-2213)
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1308
Mailing Address - Country:US
Mailing Address - Phone:860-907-3069
Mailing Address - Fax:
Practice Address - Street 1:1075 KENNEDY RD
Practice Address - Street 2:TARGET PHARMACY STORE NUMBER (T-2213)
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-1308
Practice Address - Country:US
Practice Address - Phone:860-907-3069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0008812183500000X
MAPH24120183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist