Provider Demographics
NPI:1306411970
Name:SULLIVAN, VICTORIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WITCH MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:CT
Mailing Address - Zip Code:06420-3628
Mailing Address - Country:US
Mailing Address - Phone:860-639-8675
Mailing Address - Fax:
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:CT
Practice Address - Zip Code:06248-1518
Practice Address - Country:US
Practice Address - Phone:860-228-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0012634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist