Healthcare Provider Details

I. General information

NPI: 1679772065
Provider Name (Legal Business Name): JOSHUA WADE SULLIVAN PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N PAULINE ST
MEMPHIS TN
38104-1005
US

IV. Provider business mailing address

40 DALTON CV
EADS TN
38028-6250
US

V. Phone/Fax

Practice location:
  • Phone: 901-831-2905
  • Fax:
Mailing address:
  • Phone: 931-216-2362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number29432
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: