Provider Demographics
NPI:1033264338
Name:SULLIVAN, JOHANNA LYDIA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:LYDIA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 W BAY TO BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6827
Mailing Address - Country:US
Mailing Address - Phone:813-205-5838
Mailing Address - Fax:
Practice Address - Street 1:3921 W BAY TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6827
Practice Address - Country:US
Practice Address - Phone:813-205-5838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31089183500000X
FLPU5439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist