Healthcare Provider Details

I. General information

NPI: 1285625871
Provider Name (Legal Business Name): PATRICK SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 S 4TH ST
ALBION NE
68620-1215
US

IV. Provider business mailing address

113 S 4TH ST
ALBION NE
68620-1215
US

V. Phone/Fax

Practice location:
  • Phone: 402-395-2184
  • Fax: 402-395-2185
Mailing address:
  • Phone: 402-395-2184
  • Fax: 402-395-2185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7987
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: