Provider Demographics
NPI:1134408859
Name:SUPPON, JEFFREY FRANCIS (PHARM D RPH)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:FRANCIS
Last Name:SUPPON
Suffix:
Gender:M
Credentials:PHARM D RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 TOWER DR APT 102A
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12306-6888
Mailing Address - Country:US
Mailing Address - Phone:315-952-5875
Mailing Address - Fax:
Practice Address - Street 1:139 MERCHANT PL
Practice Address - Street 2:
Practice Address - City:COBLESKILL
Practice Address - State:NY
Practice Address - Zip Code:12043-5715
Practice Address - Country:US
Practice Address - Phone:518-234-1186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist