Provider Demographics
NPI:1063684397
Name:KRUPA, JEROME (RPH)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:KRUPA
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 1:741 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2056
Mailing Address - Country:US
Mailing Address - Phone:847-577-6784
Mailing Address - Fax:
Practice Address - Street 1:741 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2056
Practice Address - Country:US
Practice Address - Phone:847-577-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-031046I183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist