Provider Demographics
NPI:1831474030
Name:FARRELL, SCOTT MICHAEL (DPHARM)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:FARRELL
Suffix:
Gender:M
Credentials:DPHARM
Other - Prefix:
Other - First Name:SCOTTY
Other - Middle Name:M
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPHARM
Mailing Address - Street 1:607 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2201
Mailing Address - Country:US
Mailing Address - Phone:920-356-0148
Mailing Address - Fax:920-346-0401
Practice Address - Street 1:607 PARK AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2201
Practice Address - Country:US
Practice Address - Phone:920-356-0148
Practice Address - Fax:920-356-0401
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14293-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist