Provider Demographics
NPI:1427139427
Name:SCOTT, MATTHEW (RPH)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:SCOTT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 FORBES RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:NY
Mailing Address - Zip Code:13684-3113
Mailing Address - Country:US
Mailing Address - Phone:315-347-4511
Mailing Address - Fax:315-347-3167
Practice Address - Street 1:4057 STATE HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:STAR LAKE
Practice Address - State:NY
Practice Address - Zip Code:13690-0211
Practice Address - Country:US
Practice Address - Phone:315-848-3784
Practice Address - Fax:315-848-5129
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042863183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist