Healthcare Provider Details

I. General information

NPI: 1639400070
Provider Name (Legal Business Name): SUNRISE ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 POWERS FERRY RD SE STE 170
MARIETTA GA
30067-9487
US

IV. Provider business mailing address

1275 POWERS FERRY RD SE SUITE 170
MARIETTA GA
30067-9486
US

V. Phone/Fax

Practice location:
  • Phone: 770-272-9612
  • Fax: 770-272-9613
Mailing address:
  • Phone: 770-272-9612
  • Fax: 770-272-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE009646
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JANE UKOH
Title or Position: OWNER
Credential:
Phone: 770-272-9612