Healthcare Provider Details

I. General information

NPI: 1477547933
Provider Name (Legal Business Name): THOMAS S. SULLIVAN M.S., R.PH., BCNSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21230 DEQUINDRE RD
WARREN MI
48091-2279
US

IV. Provider business mailing address

324 BELANGER ST
GROSSE POINTE FARMS MI
48236-3302
US

V. Phone/Fax

Practice location:
  • Phone: 586-880-2483
  • Fax:
Mailing address:
  • Phone: 313-378-5416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302025761
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number5302025761
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: