Healthcare Provider Details

I. General information

NPI: 1124195458
Provider Name (Legal Business Name): SANDRA GRACE SCOTT PHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 HWY 43
SATSUMA AL
36572
US

IV. Provider business mailing address

5807 NORTHGATE DR.
SATSUMA AL
36572
US

V. Phone/Fax

Practice location:
  • Phone: 251-675-2070
  • Fax: 251-675-7785
Mailing address:
  • Phone: 251-679-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT14115
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: