Provider Demographics
NPI:1649211632
Name:PHILLIPS, JON SCOTT (RPH)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:SCOTT
Last Name:PHILLIPS
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 1:4957 N NEWHALL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-6049
Mailing Address - Country:US
Mailing Address - Phone:414-332-6344
Mailing Address - Fax:
Practice Address - Street 1:826 N PLANKINTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-1832
Practice Address - Country:US
Practice Address - Phone:414-278-7828
Practice Address - Fax:414-273-5986
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist