Healthcare Provider Details

I. General information

NPI: 1134050966
Provider Name (Legal Business Name): MICHELLE LYNN SULLIVAN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 OAK ST SE
SALEM OR
97301-3905
US

IV. Provider business mailing address

890 OAK ST SE
SALEM OR
97301-3905
US

V. Phone/Fax

Practice location:
  • Phone: 503-814-9944
  • Fax: 503-814-5052
Mailing address:
  • Phone: 503-814-9944
  • Fax: 503-814-5052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0013763
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: