Healthcare Provider Details

I. General information

NPI: 1962290460
Provider Name (Legal Business Name): JOHN P. SULLIVAN MS, PHARMD, RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 MYSTIC VALLEY PKWY #1112
MEDFORD MA
02155-6911
US

IV. Provider business mailing address

3920 MYSTIC VALLEY PKWY #1112
MEDFORD MA
02155-6911
US

V. Phone/Fax

Practice location:
  • Phone: 617-620-1020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH1001193
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: