Provider Demographics
NPI:1639460843
Name:SULLIVAN, SYLVIA
Entity Type:Individual
Prefix:MRS
First Name:SYLVIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3511
Mailing Address - Country:US
Mailing Address - Phone:810-989-3455
Mailing Address - Fax:810-987-2087
Practice Address - Street 1:1221 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3511
Practice Address - Country:US
Practice Address - Phone:810-989-3455
Practice Address - Fax:810-987-2087
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist