Provider Demographics
NPI:1831697796
Name:SULLIVAN, MELISSA IRENE (PHARMD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:IRENE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOHENWALD
Mailing Address - State:TN
Mailing Address - Zip Code:38462-2008
Mailing Address - Country:US
Mailing Address - Phone:931-796-3284
Mailing Address - Fax:931-796-5081
Practice Address - Street 1:612 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HOHENWALD
Practice Address - State:TN
Practice Address - Zip Code:38462-2008
Practice Address - Country:US
Practice Address - Phone:931-796-3284
Practice Address - Fax:931-796-5081
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9424183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9424OtherTENNESSEE BOARD OF PHARMACY