Provider Demographics
NPI:1467048686
Name:SULLIVAN, STACIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 SIMPSON HIGHWAY 540
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114-9065
Mailing Address - Country:US
Mailing Address - Phone:601-919-7557
Mailing Address - Fax:
Practice Address - Street 1:1625 SIMPSON HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-4207
Practice Address - Country:US
Practice Address - Phone:601-849-3228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-010525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE-010525OtherLICENSE