Provider Demographics
NPI:1568733673
Name:SULLIVAN DRUGS OF LITCHFIELD INC
Entity Type:Organization
Organization Name:SULLIVAN DRUGS OF LITCHFIELD INC
Other - Org Name:SULLIVAN DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P./TRES
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-839-2909
Mailing Address - Street 1:320 E UNION AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-1575
Mailing Address - Country:US
Mailing Address - Phone:217-324-2001
Mailing Address - Fax:217-324-6001
Practice Address - Street 1:320 E UNION AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1575
Practice Address - Country:US
Practice Address - Phone:217-324-2001
Practice Address - Fax:217-324-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
IL054.0178713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133524OtherPK
IL=========001Medicaid
IL=========001Medicaid