Provider Demographics
NPI:1235452343
Name:SULLIVAN, TIMOTHY
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 ROUTE 202
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-3220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:336 ROUTE 202
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:NY
Practice Address - Zip Code:10589-3220
Practice Address - Country:US
Practice Address - Phone:914-276-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028367-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist