Provider Demographics
NPI:1134555907
Name:VAN KOOTEN, SCOTT HENRY (RPH)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:HENRY
Last Name:VAN KOOTEN
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 1:700 E RODEO RD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6451
Mailing Address - Country:US
Mailing Address - Phone:724-272-7253
Mailing Address - Fax:
Practice Address - Street 1:2785 N PINAL AVE
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-7916
Practice Address - Country:US
Practice Address - Phone:724-272-7253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020165183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS020165OtherPHARMACY PERMIT