Provider Demographics
NPI:1609955863
Name:SULLIVAN-GREEN, PENNY ANN (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:ANN
Last Name:SULLIVAN-GREEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 N REVEILLE ST
Mailing Address - Street 2:
Mailing Address - City:MAGAZINE
Mailing Address - State:AR
Mailing Address - Zip Code:72943-8422
Mailing Address - Country:US
Mailing Address - Phone:817-991-2918
Mailing Address - Fax:
Practice Address - Street 1:508 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:AR
Practice Address - Zip Code:72855-4019
Practice Address - Country:US
Practice Address - Phone:479-963-6400
Practice Address - Fax:479-963-2103
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33123183500000X
ARPD16404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist