Provider Demographics
NPI:1821758947
Name:SULLIVAN, NICOLE M (RPH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUKON
Mailing Address - State:IA
Mailing Address - Zip Code:52172
Mailing Address - Country:US
Mailing Address - Phone:563-568-6315
Mailing Address - Fax:563-568-6316
Practice Address - Street 1:21 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUKON
Practice Address - State:IA
Practice Address - Zip Code:52172
Practice Address - Country:US
Practice Address - Phone:563-568-6315
Practice Address - Fax:563-568-6316
Is Sole Proprietor?:No
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist