Healthcare Provider Details

I. General information

NPI: 1073641718
Provider Name (Legal Business Name): SUNDANCE DRUG CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

0016 KEARNS RD
SNOWMASS VLG CO
81615
US

IV. Provider business mailing address

PO BOX 6280
SNOWMASS VLG CO
81615-6280
US

V. Phone/Fax

Practice location:
  • Phone: 970-923-5890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number14-1
License Number StateCO

VIII. Authorized Official

Name: MR. STEVEN WICKES
Title or Position: OWNER
Credential:
Phone: 970-923-5890