Provider Demographics
NPI:1740994904
Name:LISZEWSKI, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:LISZEWSKI
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 1:2458 1/2 BROOKWILLOW LOOP
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-4801
Mailing Address - Country:US
Mailing Address - Phone:719-213-3568
Mailing Address - Fax:
Practice Address - Street 1:2512 BROADWAY
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81507-2758
Practice Address - Country:US
Practice Address - Phone:303-744-8660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0024267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist