Provider Demographics
NPI:1053634287
Name:SULLIVAN, ANGELIC MAURAE (RPH)
Entity Type:Individual
Prefix:
First Name:ANGELIC
Middle Name:MAURAE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 FORT HAMILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2410
Mailing Address - Country:US
Mailing Address - Phone:718-435-8800
Mailing Address - Fax:718-435-7624
Practice Address - Street 1:4514 FORT HAMILTON PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2410
Practice Address - Country:US
Practice Address - Phone:718-435-8800
Practice Address - Fax:718-435-7624
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist