Healthcare Provider Details

I. General information

NPI: 1902881097
Provider Name (Legal Business Name): SULLIVAN DRUGS OF STAUNTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MAIN ST
STAUNTON IL
62088-1446
US

IV. Provider business mailing address

101 E MAIN ST
STAUNTON IL
62088-1446
US

V. Phone/Fax

Practice location:
  • Phone: 618-635-2595
  • Fax: 618-635-5590
Mailing address:
  • Phone: 618-635-2595
  • Fax: 618-635-5590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054004541
License Number StateIL

VIII. Authorized Official

Name: MAURICE SULLIVAN
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 217-839-2909