Provider Demographics
NPI:1093085326
Name:SULLIVAN, SHANA (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
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 1:1095 US HIGHWAY 82 W
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-5803
Mailing Address - Country:US
Mailing Address - Phone:229-800-8100
Mailing Address - Fax:229-800-8101
Practice Address - Street 1:1095 US HIGHWAY 82 W
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-5803
Practice Address - Country:US
Practice Address - Phone:229-800-8100
Practice Address - Fax:229-800-8101
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist