Provider Demographics
NPI:1053662700
Name:SUPAN, ELISA MARIE CHI (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:MARIE CHI
Last Name:SUPAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2666 SKYVIEW GLEN CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77047-6818
Mailing Address - Country:US
Mailing Address - Phone:856-397-7516
Mailing Address - Fax:
Practice Address - Street 1:18220 STATE HIGHWAY 249
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4347
Practice Address - Country:US
Practice Address - Phone:281-737-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX428791835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist