Healthcare Provider Details

I. General information

NPI: 1063660728
Provider Name (Legal Business Name): EDWIN GRANT SCOTT JR. RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 S. SECOND ST.
RATON NM
87740
US

IV. Provider business mailing address

955 S. SECOND ST.
RATON NM
87740
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-3131
  • Fax: 575-445-5393
Mailing address:
  • Phone: 575-445-3131
  • Fax: 575-445-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00006144
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: