Provider Demographics
NPI:1982351474
Name:SUPCZAK, PATRICIA (RPH)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SUPCZAK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ELIOT LN
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1814
Mailing Address - Country:US
Mailing Address - Phone:413-221-4428
Mailing Address - Fax:
Practice Address - Street 1:433 CENTER ST STE 3
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056-2951
Practice Address - Country:US
Practice Address - Phone:413-583-7910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist