Provider Demographics
NPI:1205900677
Name:SULLIVAN DRUGS INC
Entity type:Organization
Organization Name:SULLIVAN DRUGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-384-2022
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:CARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30521-0069
Mailing Address - Country:US
Mailing Address - Phone:706-384-2022
Mailing Address - Fax:706-384-2118
Practice Address - Street 1:9563 LAVONIA RD
Practice Address - Street 2:
Practice Address - City:CARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30521-3254
Practice Address - Country:US
Practice Address - Phone:706-384-2022
Practice Address - Fax:706-384-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0001183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2015975OtherPK
GA00036484A4Medicaid
GA00036484A4Medicaid