Provider Demographics
NPI:1124114632
Name:SULLIVAN, JOE D JR (RPH)
Entity type:Individual
Prefix:MR
First Name:JOE
Middle Name:D
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 GRAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BACLIFF
Mailing Address - State:TX
Mailing Address - Zip Code:77518
Mailing Address - Country:US
Mailing Address - Phone:281-339-4577
Mailing Address - Fax:281-559-4339
Practice Address - Street 1:1140 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:BACLIFF
Practice Address - State:TX
Practice Address - Zip Code:77518
Practice Address - Country:US
Practice Address - Phone:281-339-4577
Practice Address - Fax:281-559-4339
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist