Provider Demographics
NPI:1629415559
Name:KUPU, SIUEA PETE
Entity Type:Individual
Prefix:
First Name:SIUEA
Middle Name:PETE
Last Name:KUPU
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 1:3571 S HIGHLANDER ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-2317
Mailing Address - Country:US
Mailing Address - Phone:801-891-1768
Mailing Address - Fax:
Practice Address - Street 1:3571 S HIGHLANDER ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84128-2317
Practice Address - Country:US
Practice Address - Phone:801-891-1768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-01
Last Update Date:2013-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17350-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist