Provider Demographics
NPI:1164474748
Name:SULLIVAN, OWEN P (RPH)
Entity Type:Individual
Prefix:MR
First Name:OWEN
Middle Name:P
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E HOEHN ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-2144
Mailing Address - Country:US
Mailing Address - Phone:217-854-8797
Mailing Address - Fax:
Practice Address - Street 1:920 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1200
Practice Address - Country:US
Practice Address - Phone:217-854-6121
Practice Address - Fax:217-854-6131
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051038956183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051038956OtherRPH NUMBER