Provider Demographics
NPI:1447255823
Name:KISSACK, JULIE C (PHARMD, BCPP)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:C
Last Name:KISSACK
Suffix:
Gender:F
Credentials:PHARMD, BCPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3088 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-9494
Mailing Address - Country:US
Mailing Address - Phone:501-305-0004
Mailing Address - Fax:501-279-5202
Practice Address - Street 1:915 E MARKET AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72149-5615
Practice Address - Country:US
Practice Address - Phone:501-279-5562
Practice Address - Fax:501-279-5202
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017520174400000X
GARPH0175201835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No174400000XOther Service ProvidersSpecialist