Provider Demographics
NPI:1386076586
Name:SULLIVAN, ADAM JACK
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:JACK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5269 CALHOUN MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-3865
Mailing Address - Country:US
Mailing Address - Phone:864-859-7168
Mailing Address - Fax:
Practice Address - Street 1:5269 CALHOUN MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-3865
Practice Address - Country:US
Practice Address - Phone:864-859-7168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist