Provider Demographics
NPI:1447569934
Name:SULLIVAN, WILLIAM MARK (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:MARK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 S BECKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1905
Mailing Address - Country:US
Mailing Address - Phone:903-594-7951
Mailing Address - Fax:903-594-7954
Practice Address - Street 1:807 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1905
Practice Address - Country:US
Practice Address - Phone:903-594-7951
Practice Address - Fax:903-594-7954
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35781183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist