Provider Demographics
NPI:1487966057
Name:SULLIVAN, LISA M (RPH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-2869
Mailing Address - Country:US
Mailing Address - Phone:781-784-1235
Mailing Address - Fax:781-784-2698
Practice Address - Street 1:800 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:MA
Practice Address - Zip Code:02067-2869
Practice Address - Country:US
Practice Address - Phone:781-784-1235
Practice Address - Fax:781-784-2698
Is Sole Proprietor?:No
Enumeration Date:2010-07-11
Last Update Date:2010-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist