Provider Demographics
NPI:1053922930
Name:AGUPUSI, NEBOLISA JOHNPAUL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:NEBOLISA
Middle Name:JOHNPAUL
Last Name:AGUPUSI
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 1:5100 SWEETBRIAR LN APT 612
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3866
Mailing Address - Country:US
Mailing Address - Phone:773-431-3039
Mailing Address - Fax:
Practice Address - Street 1:1775 W LOOP 281
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2734
Practice Address - Country:US
Practice Address - Phone:903-295-3526
Practice Address - Fax:903-295-3983
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist