Provider Demographics
NPI:1710142146
Name:SULLIVAN, CONNIE RAE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:RAE
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:PO BOX 1370
Mailing Address - Street 2:7 EAGLE NEST LANE
Mailing Address - City:LYONS
Mailing Address - State:CO
Mailing Address - Zip Code:80540-1370
Mailing Address - Country:US
Mailing Address - Phone:303-823-0406
Mailing Address - Fax:877-471-0364
Practice Address - Street 1:7 EAGLE NEST LANE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:CO
Practice Address - Zip Code:80540-1370
Practice Address - Country:US
Practice Address - Phone:303-823-0406
Practice Address - Fax:877-471-0364
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117137-8183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist