Provider Demographics
NPI:1689957656
Name:SMART, SCOTT EDWARD (RPH)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:EDWARD
Last Name:SMART
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 1:2485 W GLENLORD RD
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-9557
Mailing Address - Country:US
Mailing Address - Phone:269-429-7044
Mailing Address - Fax:269-429-7065
Practice Address - Street 1:2485 W GLENLORD RD
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9557
Practice Address - Country:US
Practice Address - Phone:269-429-7044
Practice Address - Fax:269-429-7065
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist