Provider Demographics
NPI:1851994594
Name:SULLIVAN, JOSEPH (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HANNAFORD DR
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9057
Mailing Address - Country:US
Mailing Address - Phone:207-883-7674
Mailing Address - Fax:
Practice Address - Street 1:31 HANNAFORD DR
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9057
Practice Address - Country:US
Practice Address - Phone:207-883-7674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist