Provider Demographics
NPI:1528522075
Name:SCOTT, JERRY LEE
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:SCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:KS
Mailing Address - Zip Code:67950-0637
Mailing Address - Country:US
Mailing Address - Phone:620-697-2131
Mailing Address - Fax:620-697-4643
Practice Address - Street 1:411 SUNSET ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:KS
Practice Address - Zip Code:67950-5001
Practice Address - Country:US
Practice Address - Phone:620-697-2131
Practice Address - Fax:620-697-4643
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-09441183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1-09441OtherKANSAS PHARMACY LICENSE