Provider Demographics
NPI:1093726580
Name:SULLIVAN S DRUG LLC
Entity Type:Organization
Organization Name:SULLIVAN S DRUG LLC
Other - Org Name:SULLIVAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:RANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-793-3738
Mailing Address - Street 1:1140 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BACLIFF
Mailing Address - State:TX
Mailing Address - Zip Code:77518-2760
Mailing Address - Country:US
Mailing Address - Phone:281-339-4577
Mailing Address - Fax:281-559-4339
Practice Address - Street 1:1140 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BACLIFF
Practice Address - State:TX
Practice Address - Zip Code:77518-2760
Practice Address - Country:US
Practice Address - Phone:281-339-4577
Practice Address - Fax:281-559-4339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133093336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150045Medicaid
4577219OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0435690001Medicare NSC