Provider Demographics
NPI:1649891649
Name:SCOTT, WALTER G
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:G
Last Name:SCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MONTAGUE RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-1153
Mailing Address - Country:US
Mailing Address - Phone:302-379-5215
Mailing Address - Fax:
Practice Address - Street 1:1601 KIRKWOOD HWY RM 139
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-4917
Practice Address - Country:US
Practice Address - Phone:302-994-2511
Practice Address - Fax:302-633-5578
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0003324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist