Healthcare Provider Details

I. General information

NPI: 1477669315
Provider Name (Legal Business Name): EDWARD JOHN SULLIVAN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 CHALKSTONE AVE
PROVIDENCE RI
02908-4734
US

IV. Provider business mailing address

161 CURTIS ST
CRANSTON RI
02920-1823
US

V. Phone/Fax

Practice location:
  • Phone: 401-457-3048
  • Fax:
Mailing address:
  • Phone: 401-440-9695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number04216
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: