Provider Demographics
NPI:1144877804
Name:SULLIVAN, CASSANDRA (RPH)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 WOODLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-9790
Mailing Address - Country:US
Mailing Address - Phone:662-236-1478
Mailing Address - Fax:
Practice Address - Street 1:502 WOODLAND HILLS DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-9790
Practice Address - Country:US
Practice Address - Phone:662-236-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10656183500000X
MST-09630183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MST-09630OtherMS LICENSE NUMBER