Provider Demographics
NPI:1699007930
Name:SCHUPP, JERRY A (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:A
Last Name:SCHUPP
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 1:2304 MISSOURI BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-4729
Mailing Address - Country:US
Mailing Address - Phone:573-634-4400
Mailing Address - Fax:573-636-0672
Practice Address - Street 1:2304 MISSOURI BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-4729
Practice Address - Country:US
Practice Address - Phone:573-634-4400
Practice Address - Fax:573-636-0672
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO29259183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist