Active NPI
Jack Sullivan
- Pharmacist
- Woodsville, NH
National Provider Identifier
1104631399
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- PHCY-05103
- Practice address
- 4901 Dartmouth College Hwy
Woodsville, NH 03785-1412 - Phone
- (603) 747-3355
- NPI assigned
- Feb 12, 2025
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | PHCY-05103 | NH | Primary |
Addresses
Primary practice location
4901 Dartmouth College Hwy
Woodsville, NH 03785-1412
Mailing address
102 Highland Ave
Saint Johnsbury, VT 05819-2577
Phone (603) 723-3016
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PHCY-05103 | NH | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Wal-Mart Stores East, LP | Community/Retail Pharmacy | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1739318400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1742774400000",
"number": "1104631399",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "102 HIGHLAND AVE",
"city": "SAINT JOHNSBURY",
"state": "VT",
"postal_code": "058192577",
"telephone_number": "603-723-3016"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4901 DARTMOUTH COLLEGE HWY",
"city": "WOODSVILLE",
"state": "NH",
"postal_code": "037851412",
"telephone_number": "603-747-3355"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SULLIVAN",
"first_name": "JACK",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2025-02-12",
"last_updated": "2025-03-24",
"certification_date": "2025-03-24",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Pharmacist",
"state": "NH",
"license": "PHCY-05103",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Woodsville, NH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 24, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.