Provider Demographics
NPI:1770508749
Name:SULLIVAN, MAURICE E (R PH)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:GILLESPIE
Mailing Address - State:IL
Mailing Address - Zip Code:62033
Mailing Address - Country:US
Mailing Address - Phone:217-839-2909
Mailing Address - Fax:217-839-1300
Practice Address - Street 1:801 N OBANNON ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:IL
Practice Address - Zip Code:62560-5283
Practice Address - Country:US
Practice Address - Phone:217-839-2909
Practice Address - Fax:217-839-1300
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL51-027702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL0658070001Medicare NSC