Provider Demographics
NPI:1215064340
Name:SULLIVAN S DRUG LLC
Entity type:Organization
Organization Name:SULLIVAN S DRUG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:
Authorized Official - Last Name:RANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-793-3738
Mailing Address - Street 1:1140 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BACLIFF
Mailing Address - State:TX
Mailing Address - Zip Code:77518-2760
Mailing Address - Country:US
Mailing Address - Phone:281-339-4577
Mailing Address - Fax:281-559-4339
Practice Address - Street 1:1140 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BACLIFF
Practice Address - State:TX
Practice Address - Zip Code:77518-2760
Practice Address - Country:US
Practice Address - Phone:281-339-4577
Practice Address - Fax:281-559-4339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13309332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX011509901Medicaid
TX010086901Medicaid