Healthcare Provider Details

I. General information

NPI: 1548219694
Provider Name (Legal Business Name): KENNETH SCOTT NELSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 S. MAIN LUCK PHARMACY INC
LUCK WI
54853
US

IV. Provider business mailing address

402 ROCK RIDGE TRL
MILLTOWN WI
54858-4421
US

V. Phone/Fax

Practice location:
  • Phone: 715-472-2122
  • Fax:
Mailing address:
  • Phone: 715-825-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11412-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: