Provider Demographics
NPI:1376062893
Name:SULLIVAN, JILL R (DPH)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-1003
Mailing Address - Country:US
Mailing Address - Phone:423-775-5511
Mailing Address - Fax:423-775-5204
Practice Address - Street 1:6985 RHEA COUNTY HWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-6208
Practice Address - Country:US
Practice Address - Phone:423-775-5511
Practice Address - Fax:423-775-5204
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN244869OtherNABP