Healthcare Provider Details

I. General information

NPI: 1821476169
Provider Name (Legal Business Name): MICHELLE SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 EASTMAN RD
CENTER CONWAY NH
03813-4221
US

IV. Provider business mailing address

25 HARRIS ST APT 6
ACTON MA
01720-4111
US

V. Phone/Fax

Practice location:
  • Phone: 603-356-5471
  • Fax:
Mailing address:
  • Phone: 978-856-5090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR2412
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH233288
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: