Active NPI
Jacob Sullivan, RPH
- Pharmacist
- Liberty Lake, WA
National Provider Identifier
1164916656
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- PH00069866
- Practice address
- 23102 E Appleway Ave
Liberty Lake, WA 99019-9585 - Phone
- (509) 928-8738
- NPI assigned
- Jun 18, 2018
- 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 | PH00069866 | WA | Primary |
Addresses
Primary practice location
23102 E Appleway Ave
Liberty Lake, WA 99019-9585
Mailing address
PO Box 608
Newman Lake, WA 99025-0608
Phone (509) 981-8315
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
- Credentials
- Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PH00069866 | WA | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1529280000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1529280000000",
"number": "1164916656",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 608",
"city": "NEWMAN LAKE",
"state": "WA",
"postal_code": "990250608",
"telephone_number": "509-981-8315"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "23102 E APPLEWAY AVE",
"city": "LIBERTY LAKE",
"state": "WA",
"postal_code": "990199585",
"telephone_number": "509-928-8738"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SULLIVAN",
"first_name": "JACOB",
"credential": "RPH",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2018-06-18",
"last_updated": "2018-06-18",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "WA",
"license": "PH00069866",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Liberty Lake, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 18, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.