Provider Demographics
NPI:1528313574
Name:SULLIVAN, JENNIFER LEIGH (PHARMD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 STONEWALL BEACH LN
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6709
Mailing Address - Country:US
Mailing Address - Phone:704-799-3449
Mailing Address - Fax:
Practice Address - Street 1:559 RIVER HWY
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6829
Practice Address - Country:US
Practice Address - Phone:704-633-3438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist