Provider Demographics
NPI:1023315413
Name:SHUPE, ALLAN VAN (RPH)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:VAN
Last Name:SHUPE
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 1:1733 POWDER SPRINGS RD SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4863
Mailing Address - Country:US
Mailing Address - Phone:770-427-6724
Mailing Address - Fax:770-919-8610
Practice Address - Street 1:1733 POWDER SPRINGS RD SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4863
Practice Address - Country:US
Practice Address - Phone:770-427-6724
Practice Address - Fax:770-919-8610
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist