Provider Demographics
NPI:1740402288
Name:LACKEY, SCOTT PATRICK (RPH)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:PATRICK
Last Name:LACKEY
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:HWY 19E 310 WEST BYPASS AVE
Mailing Address - Street 2:P O BOX 1768
Mailing Address - City:BURNSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28714
Mailing Address - Country:US
Mailing Address - Phone:828-682-9901
Mailing Address - Fax:828-682-9930
Practice Address - Street 1:310 WEST BYPASS HWY19E
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28714
Practice Address - Country:US
Practice Address - Phone:828-682-9901
Practice Address - Fax:828-682-9930
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10279183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0005102Medicaid
BB8609755OtherDEA
5079710001Medicare ID - Type Unspecified