Provider Demographics
NPI:1477547933
Name:SULLIVAN, THOMAS S (MS, RPH, BCNSP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MS, RPH, BCNSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 BELANGER ST
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3302
Mailing Address - Country:US
Mailing Address - Phone:313-378-5416
Mailing Address - Fax:
Practice Address - Street 1:21230 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2279
Practice Address - Country:US
Practice Address - Phone:586-880-2483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025761183500000X, 1835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No183500000XPharmacy Service ProvidersPharmacist