Provider Demographics
NPI:1124646609
Name:CUPPLES, PHILLIP ANDREW MICHAEL (PHARMD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ANDREW MICHAEL
Last Name:CUPPLES
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 S 199TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-1390
Mailing Address - Country:US
Mailing Address - Phone:918-932-5896
Mailing Address - Fax:
Practice Address - Street 1:2415 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-2232
Practice Address - Country:US
Practice Address - Phone:918-542-8429
Practice Address - Fax:915-542-8420
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK17407OtherPHARMACIST LICENSE