Healthcare Provider Details

I. General information

NPI: 1164250544
Provider Name (Legal Business Name): CHANDLER SHANNON CUPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 PELHAM RD S
JACKSONVILLE AL
36265-3314
US

IV. Provider business mailing address

537 NUNNALLY LAKE RD
OHATCHEE AL
36271-7671
US

V. Phone/Fax

Practice location:
  • Phone: 256-435-1071
  • Fax:
Mailing address:
  • Phone: 256-473-1135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS13891
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: