Provider Demographics
NPI:1104631399
Name:SULLIVAN, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-2577
Mailing Address - Country:US
Mailing Address - Phone:603-723-3016
Mailing Address - Fax:
Practice Address - Street 1:4901 DARTMOUTH COLLEGE HWY
Practice Address - Street 2:
Practice Address - City:WOODSVILLE
Practice Address - State:NH
Practice Address - Zip Code:03785-1412
Practice Address - Country:US
Practice Address - Phone:603-747-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-12
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPHCY-05103183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty