Provider Demographics
NPI:1740230093
Name:SULLIVAN, ROBERT S JR (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2784 STATE HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-4914
Mailing Address - Country:US
Mailing Address - Phone:518-835-3430
Mailing Address - Fax:518-835-6022
Practice Address - Street 1:2 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-2623
Practice Address - Country:US
Practice Address - Phone:518-762-8319
Practice Address - Fax:518-762-5272
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist