MEDICARE: ANGELIC MAURAE SULLIVAN RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	046157	NY

General Provider Information

NPI Number	:	1053634287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELIC MAURAE SULLIVAN RPH

Provider Business Mailing Address
First Line	:	4514 FORT HAMILTON PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-2410
Country	:	US
Telephone Number	:	718-435-8800
Fax Number	:	718-435-7624

Provider Business Practice Location Address
First Line	:	4514 FORT HAMILTON PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-2410
Country	:	US
Telephone Number	:	718-435-8800
Fax Number	:	718-435-7624

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2010
Last Update Date	:	03/02/2010

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