Provider Demographics
NPI:1821407941
Name:SUPAK, JOHN PAUL (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:SUPAK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 N BRYANT BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-2865
Mailing Address - Country:US
Mailing Address - Phone:325-655-4957
Mailing Address - Fax:325-659-5159
Practice Address - Street 1:2828 N BRYANT BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-2865
Practice Address - Country:US
Practice Address - Phone:325-655-4957
Practice Address - Fax:325-659-5159
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist