Provider Demographics
NPI:1295414985
Name:SHUPP, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:SHUPP
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 1:11210 NAVAJO LN APT 312
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-9043
Mailing Address - Country:US
Mailing Address - Phone:330-464-8392
Mailing Address - Fax:
Practice Address - Street 1:2500 METROHEALTH DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1900
Practice Address - Country:US
Practice Address - Phone:216-778-4508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03443242183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist