Healthcare Provider Details

I. General information

NPI: 1801168034
Provider Name (Legal Business Name): SUNSET PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4224 CLEVELAND AVE STE 5 FIRST FLOOR
FORT MYERS FL
33901-9051
US

IV. Provider business mailing address

4224 CLEVELAND AVE STE 5
FORT MYERS FL
33901-9051
US

V. Phone/Fax

Practice location:
  • Phone: 239-225-6337
  • Fax: 239-437-6337
Mailing address:
  • Phone: 239-225-6337
  • Fax: 239-437-6337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberPH 24933
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5708966
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP PROVIDER IDENTIFICATION NUMBER
# 2
Identifier003508600
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name: COURTLAND TWYMAN
Title or Position: MANING PARTNER
Credential:
Phone: 239-225-6337