Provider Demographics
NPI:1306109368
Name:SULLIVAN, WENDA (BS, PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:WENDA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:BS, PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 S HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-6424
Mailing Address - Country:US
Mailing Address - Phone:850-968-3318
Mailing Address - Fax:850-968-1064
Practice Address - Street 1:1550 S HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-6424
Practice Address - Country:US
Practice Address - Phone:850-968-3318
Practice Address - Fax:850-968-1064
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-24
Last Update Date:2012-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS33955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist