Healthcare Provider Details

I. General information

NPI: 1972179893
Provider Name (Legal Business Name): TIMOTHY JAMES SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 SOUTH ST
CONCORD NH
03301-2826
US

IV. Provider business mailing address

92 SOUTH ST
CONCORD NH
03301-2826
US

V. Phone/Fax

Practice location:
  • Phone: 603-228-8400
  • Fax: 603-228-0272
Mailing address:
  • Phone: 603-831-3056
  • Fax: 603-228-0272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPT123588
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: