Provider Demographics
NPI:1801377726
Name:SULLIVAN, KATHLEEN (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 MATCHETT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-1516
Mailing Address - Country:US
Mailing Address - Phone:973-617-7068
Mailing Address - Fax:
Practice Address - Street 1:1603 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-1951
Practice Address - Country:US
Practice Address - Phone:617-267-5109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH237662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist