Provider Demographics
NPI:1831402221
Name:SULKOSKY, EDWARD HOWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:HOWARD
Last Name:SULKOSKY
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 1:1633 LAKE MARINA DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4642
Mailing Address - Country:US
Mailing Address - Phone:423-876-7374
Mailing Address - Fax:
Practice Address - Street 1:4038 DAYTON BLVD
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:TN
Practice Address - Zip Code:37415-7123
Practice Address - Country:US
Practice Address - Phone:423-877-2431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3291183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist