Healthcare Provider Details

I. General information

NPI: 1891192761
Provider Name (Legal Business Name): SCOTT JAGORA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 HARTFORD TPKE
WATERFORD CT
06385-4246
US

IV. Provider business mailing address

900 HARTFORD TPKE
WATERFORD CT
06385-4246
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-3171
  • Fax:
Mailing address:
  • Phone: 860-443-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPCT.0013095
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: