Organization
SULLIVAN'S DRUG STORE,INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RANDELL GLENN SULLIVAN R.PH. (OWNER)
(662) 563-7687
Entity
Organization
Contact information
Practice address
107 VAN VORIS ST, BATESVILLE, MS 38606-2198
(662) 563-7687
(662) 563-0260
Mailing address
107 VAN VORIS ST, BATESVILLE, MS 38606-2198
(662) 563-7687
(662) 563-0260
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
00481/01.1
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00034444
—
MS
Enumeration date
11/02/2006
Last updated
08/22/2020
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