Provider Demographics
NPI:1477539732
Name:MAURICE E SULLIVAN
Entity Type:Organization
Organization Name:MAURICE E SULLIVAN
Other - Org Name:SULLIVAN DRUG OF RAYMOND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-839-2909
Mailing Address - Street 1:PO BOX 588
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:IL
Mailing Address - Zip Code:62560-0588
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 N OBANNON ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:IL
Practice Address - Zip Code:62560-5283
Practice Address - Country:US
Practice Address - Phone:217-229-3022
Practice Address - Fax:217-229-3065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IL0540075023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2018616OtherPK
IL323389477001Medicaid
2018616OtherPK