Provider Demographics
NPI:1538245022
Name:SULLIVAN, STEVE HADEN (PD)
Entity type:Individual
Prefix:
First Name:STEVE
Middle Name:HADEN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 W HIGHWAY 70 B
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-2928
Mailing Address - Country:US
Mailing Address - Phone:870-584-4676
Mailing Address - Fax:870-832-5405
Practice Address - Street 1:208 MAIN ST.
Practice Address - Street 2:
Practice Address - City:HORATIO
Practice Address - State:AR
Practice Address - Zip Code:71842
Practice Address - Country:US
Practice Address - Phone:870-832-2561
Practice Address - Fax:870-832-5405
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06508183500000X
OK9163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist