Provider Demographics
NPI:1639217623
Name:SULLIVAN PHARMACEUTICALS INC
Entity Type:Organization
Organization Name:SULLIVAN PHARMACEUTICALS INC
Other - Org Name:MONTCLAIR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-339-9393
Mailing Address - Street 1:6123 LA SALLE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2801
Mailing Address - Country:US
Mailing Address - Phone:510-339-9393
Mailing Address - Fax:510-339-9394
Practice Address - Street 1:6123 LA SALLE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2801
Practice Address - Country:US
Practice Address - Phone:510-339-9393
Practice Address - Fax:510-339-9394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY382593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0539431OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA382590Medicaid