Provider Demographics
NPI:1164956421
Name:SULLIVAN, STEPHEN JOHN JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOHN
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HOLLOMAN AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88330-8273
Mailing Address - Country:US
Mailing Address - Phone:575-572-7436
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE # 673MDG
Practice Address - Street 2:
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:907-580-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP000086281835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist