Healthcare Provider Details

I. General information

NPI: 1124646609
Provider Name (Legal Business Name): PHILLIP ANDREW MICHAEL CUPPLES PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N MAIN ST
MIAMI OK
74354-2232
US

IV. Provider business mailing address

3801 S 199TH EAST AVE
BROKEN ARROW OK
74014-1390
US

V. Phone/Fax

Practice location:
  • Phone: 918-542-8429
  • Fax: 915-542-8420
Mailing address:
  • Phone: 918-932-5896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17407
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: