Provider Demographics
NPI:1598074411
Name:SULLIVANS HOMETOWN PHARMACY LLC
Entity Type:Organization
Organization Name:SULLIVANS HOMETOWN PHARMACY LLC
Other - Org Name:SULLIVANS HOMETOWN PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-474-5050
Mailing Address - Street 1:231 NORTHGATE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1426
Mailing Address - Country:US
Mailing Address - Phone:931-474-5050
Mailing Address - Fax:931-474-5053
Practice Address - Street 1:231 NORTHGATE DR STE 100
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1436
Practice Address - Country:US
Practice Address - Phone:931-474-5050
Practice Address - Fax:931-474-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN47943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4443583OtherNCPDP PROVIDER IDENTIFICATION NUMBER