Provider Demographics
NPI:1073348629
Name:SULLIVAN, JOHN PETER
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PETER
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 1:16 CALLE DEL MEDIA
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-7421
Mailing Address - Country:US
Mailing Address - Phone:832-865-2880
Mailing Address - Fax:
Practice Address - Street 1:16 CALLE DEL MEDIA
Practice Address - Street 2:
Practice Address - City:TIJERAS
Practice Address - State:NM
Practice Address - Zip Code:87059-7421
Practice Address - Country:US
Practice Address - Phone:832-865-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00007398183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty