Provider Demographics
NPI:1821364670
Name:SULLIVAN, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
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 1:13831 CHALCO VALLEY PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68138-6101
Mailing Address - Country:US
Mailing Address - Phone:402-592-5244
Mailing Address - Fax:
Practice Address - Street 1:13831 CHALCO VALLEY PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68138-6101
Practice Address - Country:US
Practice Address - Phone:402-592-5244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician