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General NPI Number Information
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NPI Number | 1104631399
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Entity Type | Individual
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Provider Name | JACK SULLIVAN
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Gender | Male
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Dates
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Enumeration Date | 02/12/2025
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Last Update Date | 03/24/2025
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Provider Practice Location Address
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Address Line | 4901 DARTMOUTH COLLEGE HWY
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City | WOODSVILLE
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State | NH
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Zip | 03785-1412
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Country | US
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Telephone | 603-747-3355
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Fax |
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Provider Business Mailing Address
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Address Line | 102 HIGHLAND AVE
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City | SAINT JOHNSBURY
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State | VT
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Zip | 05819-2577
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Country | US
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Telephone | 603-723-3016
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PHCY-05103
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License Number State | NH
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