Provider Demographics
NPI:1215064050
Name:SULLIVAN, THOMAS EDWARD (RPH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EDWARD
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 1:1563 BARRINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3619
Mailing Address - Country:US
Mailing Address - Phone:904-940-1680
Mailing Address - Fax:
Practice Address - Street 1:1010 S. PONCE DELEON BLVD
Practice Address - Street 2:WINN-DIXIE PHARMACY
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084
Practice Address - Country:US
Practice Address - Phone:904-825-2181
Practice Address - Fax:904-829-3643
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25069183500000X
NCNC 8523183500000X
MAMA 15211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist