Provider Demographics
NPI:1760520373
Name:SUPALLA, WILLIAM J (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:J
Last Name:SUPALLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3819 CEDAR CREEK CT
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-2432
Mailing Address - Country:US
Mailing Address - Phone:507-235-8541
Mailing Address - Fax:
Practice Address - Street 1:322 S STATE ST
Practice Address - Street 2:FIVE LAKES CENTRE
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4139
Practice Address - Country:US
Practice Address - Phone:507-238-2797
Practice Address - Fax:507-238-4701
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111504-6183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist