Provider Demographics
NPI:1700965811
Name:SULLIVAN'S DRUG STORE,INC
Entity Type:Organization
Organization Name:SULLIVAN'S DRUG STORE,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDELL
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-563-7687
Mailing Address - Street 1:107 VAN VORIS ST
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-2198
Mailing Address - Country:US
Mailing Address - Phone:662-563-7687
Mailing Address - Fax:662-563-0260
Practice Address - Street 1:107 VAN VORIS ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-2198
Practice Address - Country:US
Practice Address - Phone:662-563-7687
Practice Address - Fax:662-563-0260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00481/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00034444Medicaid