Provider Demographics
NPI:1972179893
Name:SULLIVAN, TIMOTHY JAMES
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
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 1:92 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2826
Mailing Address - Country:US
Mailing Address - Phone:603-831-3056
Mailing Address - Fax:603-228-0272
Practice Address - Street 1:92 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2826
Practice Address - Country:US
Practice Address - Phone:603-228-8400
Practice Address - Fax:603-228-0272
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPT123588183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician