Provider Demographics
NPI:1194843128
Name:SULLIVAN, JEFFREY P (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:P
Last Name:SULLIVAN
Suffix:
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 1:1261 FOXTAIL DR
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-7795
Mailing Address - Country:US
Mailing Address - Phone:406-755-8612
Mailing Address - Fax:406-756-3528
Practice Address - Street 1:310 SUNNYVIEW LN
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3129
Practice Address - Country:US
Practice Address - Phone:406-752-1761
Practice Address - Fax:406-756-3528
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5811183500000X
NV15036183500000X
WY2958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist