Provider Demographics
NPI:1316659782
Name:SULLIVAN, JESSE BRIAN (PHARMD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:BRIAN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 AUTUMN DR
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-7444
Mailing Address - Country:US
Mailing Address - Phone:516-476-5674
Mailing Address - Fax:
Practice Address - Street 1:99 HIGHWAY 37 W
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6423
Practice Address - Country:US
Practice Address - Phone:732-557-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-16
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI035531001835C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0205XPharmacy Service ProvidersPharmacistCritical Care