Provider Demographics
NPI:1639479710
Name:SULLIVAN, SUSAN LEE (RPH)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
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 1:19266 COASTAL HWY
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-6117
Mailing Address - Country:US
Mailing Address - Phone:302-226-8410
Mailing Address - Fax:302-226-8461
Practice Address - Street 1:19266 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-6117
Practice Address - Country:US
Practice Address - Phone:302-226-8410
Practice Address - Fax:302-226-8461
Is Sole Proprietor?:No
Enumeration Date:2010-10-24
Last Update Date:2010-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0003356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist