Provider Demographics
NPI:1366042145
Name:SULLIVAN, TOM
Entity Type:Individual
Prefix:
First Name:TOM
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 1:3302 MACH 1 DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-3098
Mailing Address - Country:US
Mailing Address - Phone:402-649-1821
Mailing Address - Fax:
Practice Address - Street 1:2400 W PASEWALK AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4608
Practice Address - Country:US
Practice Address - Phone:402-371-6232
Practice Address - Fax:402-371-9485
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist