Healthcare Provider Details

I. General information

NPI: 1467048686
Provider Name (Legal Business Name): STACIE SULLIVAN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2020
Last Update Date: 12/13/2020
Certification Date: 12/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 SIMPSON HIGHWAY 49
MAGEE MS
39111-4207
US

IV. Provider business mailing address

543 SIMPSON HIGHWAY 540
MENDENHALL MS
39114-9065
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-3228
  • Fax:
Mailing address:
  • Phone: 601-919-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-010525
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: