Provider Demographics
NPI:1801190194
Name:SULLIVAN, CHARLES ROBERT
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROBERT
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1478
Mailing Address - Country:US
Mailing Address - Phone:541-267-1709
Mailing Address - Fax:
Practice Address - Street 1:230 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1478
Practice Address - Country:US
Practice Address - Phone:541-267-1709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-31
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0012450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist