Provider Demographics
NPI:1700472941
Name:SCOTT, WADE WARRICK (RPH)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:WARRICK
Last Name:SCOTT
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:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31203-2267
Mailing Address - Country:US
Mailing Address - Phone:478-742-3098
Mailing Address - Fax:478-750-8575
Practice Address - Street 1:635 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-3531
Practice Address - Country:US
Practice Address - Phone:478-742-3098
Practice Address - Fax:478-750-8575
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH013432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist