Provider Demographics
NPI:1073004263
Name:SULLIVAN, TAYLOR JEAN
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2813
Mailing Address - Country:US
Mailing Address - Phone:518-828-9469
Mailing Address - Fax:
Practice Address - Street 1:617 WARREN ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2813
Practice Address - Country:US
Practice Address - Phone:518-828-9469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0634241835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist