Provider Demographics
NPI:1689855777
Name:SULLIVAN, JACINTA MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JACINTA
Middle Name:MARIE
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 1:2330 NIAGARA FALLS BLVD
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-4759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2330 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-4759
Practice Address - Country:US
Practice Address - Phone:716-693-9666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044647183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01478871Medicaid