Healthcare Provider Details

I. General information

NPI: 1215064050
Provider Name (Legal Business Name): THOMAS EDWARD SULLIVAN R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 S. PONCE DELEON BLVD WINN-DIXIE PHARMACY
ST AUGUSTINE FL
32084
US

IV. Provider business mailing address

1563 BARRINGTON CIR
ST AUGUSTINE FL
32092-3619
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-2181
  • Fax: 904-829-3643
Mailing address:
  • Phone: 904-940-1680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS25069
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberNC 8523
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberMA 15211
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: