Provider Demographics
NPI:1053396028
Name:SULLIVAN WHOLESALE DRUG CO INC
Entity type:Organization
Organization Name:SULLIVAN WHOLESALE DRUG CO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND RPH
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:217-532-2377
Mailing Address - Street 1:325 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62049-1460
Mailing Address - Country:US
Mailing Address - Phone:217-532-2377
Mailing Address - Fax:217-532-3037
Practice Address - Street 1:325 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:IL
Practice Address - Zip Code:62049-1460
Practice Address - Country:US
Practice Address - Phone:217-532-2377
Practice Address - Fax:217-532-3037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IL054.0136043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2023150OtherPK
IL371005938001Medicaid
0654420001Medicare NSC