Provider Demographics
NPI:1710477062
Name:SULLIVAN, KAITLYN MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 MANUEL DR
Mailing Address - Street 2:
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-4154
Mailing Address - Country:US
Mailing Address - Phone:814-952-9237
Mailing Address - Fax:
Practice Address - Street 1:738 LITTLE DEER CREEK VALLEY RD
Practice Address - Street 2:
Practice Address - City:RUSSELLTON
Practice Address - State:PA
Practice Address - Zip Code:15076-1333
Practice Address - Country:US
Practice Address - Phone:724-265-1632
Practice Address - Fax:724-265-1120
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-12
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP4520643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1036260510001Medicaid