Provider Demographics
NPI:1922204916
Name:SKINNER, SCOTT
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:SKINNER
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 1:4399 E GOGOMAIN RD
Mailing Address - Street 2:
Mailing Address - City:PICKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49774-9147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 EAST M 134
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:MI
Practice Address - Zip Code:49719
Practice Address - Country:US
Practice Address - Phone:906-484-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist