Healthcare Provider Details

I. General information

NPI: 1538245022
Provider Name (Legal Business Name): STEVE HADEN SULLIVAN P.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 MAIN ST.
HORATIO AR
71842
US

IV. Provider business mailing address

414 W HIGHWAY 70 B
DE QUEEN AR
71832-2928
US

V. Phone/Fax

Practice location:
  • Phone: 870-832-2561
  • Fax: 870-832-5405
Mailing address:
  • Phone: 870-584-4676
  • Fax: 870-832-5405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD06508
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9163
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: