Healthcare Provider Details

I. General information

NPI: 1609955863
Provider Name (Legal Business Name): PENNY ANN SULLIVAN-GREEN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 E WALNUT ST
PARIS AR
72855-4019
US

IV. Provider business mailing address

129 N REVEILLE ST
MAGAZINE AR
72943-8422
US

V. Phone/Fax

Practice location:
  • Phone: 479-963-6400
  • Fax: 479-963-2103
Mailing address:
  • Phone: 817-991-2918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number33123
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD16404
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: