Provider Demographics
NPI:1407456981
Name:SULLENS, TIMOTHY JOHN
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:SULLENS
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 1:1001 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-3774
Mailing Address - Country:US
Mailing Address - Phone:618-292-3464
Mailing Address - Fax:618-392-3260
Practice Address - Street 1:1001 N WEST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-3774
Practice Address - Country:US
Practice Address - Phone:618-292-3464
Practice Address - Fax:618-392-3260
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051038950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist