Healthcare Provider Details

I. General information

NPI: 1629415559
Provider Name (Legal Business Name): SIUEA PETE KUPU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2013
Last Update Date: 06/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3571 S HIGHLANDER ST
SALT LAKE CITY UT
84128-2317
US

IV. Provider business mailing address

3571 S HIGHLANDER ST
SALT LAKE CITY UT
84128-2317
US

V. Phone/Fax

Practice location:
  • Phone: 801-891-1768
  • Fax:
Mailing address:
  • Phone: 801-891-1768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17350-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: