Provider Demographics
NPI:1518232073
Name:SULLIVAN, MARY ELIZABETH (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 STOCKWELL DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MA
Mailing Address - Zip Code:02322-1149
Mailing Address - Country:US
Mailing Address - Phone:508-232-4003
Mailing Address - Fax:508-232-4011
Practice Address - Street 1:120 STOCKWELL DR
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:MA
Practice Address - Zip Code:02322-1149
Practice Address - Country:US
Practice Address - Phone:508-232-4003
Practice Address - Fax:508-232-4011
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist