MEDICARE: CHANDLER SHANNON CUPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	S13891	AL

General Provider Information

NPI Number	:	1164250544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANDLER SHANNON CUPP

Provider Business Mailing Address
First Line	:	537 NUNNALLY LAKE RD
Second Line	:
City	:	OHATCHEE
State	:	AL
Zip	:	36271-7671
Country	:	US
Telephone Number	:	256-473-1135
Fax Number	:

Provider Business Practice Location Address
First Line	:	1625 PELHAM RD S
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-3314
Country	:	US
Telephone Number	:	256-435-1071
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2024
Last Update Date	:	07/25/2024

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Directions to “ CHANDLER SHANNON CUPP ” Practice Location

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