Provider Demographics
NPI:1649648189
Name:SULLIVAN, VALERIE FAYE (RPH)
Entity type:Individual
Prefix:MRS
First Name:VALERIE
Middle Name:FAYE
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 1:2800 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801
Mailing Address - Country:US
Mailing Address - Phone:662-840-1022
Mailing Address - Fax:662-840-4677
Practice Address - Street 1:2800 WEST MAIN STREET
Practice Address - Street 2:SENIOR RX
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-840-1022
Practice Address - Fax:662-840-4677
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-07091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist