1801168034 NPI number — SUNSET PHARMACY LLC

Table of content: (NPI 1801168034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801168034 NPI number — SUNSET PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNSET PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SUNSET PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801168034
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4224 CLEVELAND AVE STE 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33901-9051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-225-6337
Provider Business Mailing Address Fax Number:
239-437-6337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4224 CLEVELAND AVE STE 5
Provider Second Line Business Practice Location Address:
FIRST FLOOR
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33901-9051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-225-6337
Provider Business Practice Location Address Fax Number:
239-437-6337
Provider Enumeration Date:
02/03/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TWYMAN
Authorized Official First Name:
COURTLAND
Authorized Official Middle Name:
Authorized Official Title or Position:
MANING PARTNER
Authorized Official Telephone Number:
239-225-6337

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: PH 24933 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5708966 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 003508600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".