MEDICARE: ADAM JACK SULLIVAN

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	13316	SC

General Provider Information

NPI Number	:	1386076586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADAM JACK SULLIVAN

Provider Business Mailing Address
First Line	:	5269 CALHOUN MEMORIAL HWY
Second Line	:
City	:	EASLEY
State	:	SC
Zip	:	29640-3865
Country	:	US
Telephone Number	:	864-859-7168
Fax Number	:

Provider Business Practice Location Address
First Line	:	5269 CALHOUN MEMORIAL HWY
Second Line	:
City	:	EASLEY
State	:	SC
Zip	:	29640-3865
Country	:	US
Telephone Number	:	864-859-7168
Fax Number	:

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

Provider Enumeration Date	:	07/30/2013
Last Update Date	:	07/30/2013

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