Provider Demographics
NPI:1821476169
Name:SULLIVAN, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HARRIS ST APT 6
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-4111
Mailing Address - Country:US
Mailing Address - Phone:978-856-5090
Mailing Address - Fax:
Practice Address - Street 1:1150 EASTMAN RD
Practice Address - Street 2:
Practice Address - City:CENTER CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03813-4221
Practice Address - Country:US
Practice Address - Phone:603-356-5471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR2412183500000X
MAPH233288183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist