Provider Demographics
NPI:1902197635
Name:SUPEY, VERA LYNN
Entity Type:Individual
Prefix:
First Name:VERA
Middle Name:LYNN
Last Name:SUPEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 RICHARD DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-1319
Mailing Address - Country:US
Mailing Address - Phone:570-675-9346
Mailing Address - Fax:
Practice Address - Street 1:2810 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:SHAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18708
Practice Address - Country:US
Practice Address - Phone:570-675-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP042101L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist