Provider Demographics
NPI:1124337068
Name:SULLIVAN, TIMOTHY (RPH)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SULLIVAN
Suffix:
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 1:811 FISCHER BLVD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-4605
Mailing Address - Country:US
Mailing Address - Phone:732-929-3440
Mailing Address - Fax:
Practice Address - Street 1:811 FISCHER BLVD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-4605
Practice Address - Country:US
Practice Address - Phone:732-929-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRI02712600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist