Healthcare Provider Details

I. General information

NPI: 1871748012
Provider Name (Legal Business Name): SUNNYSIDE DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E MULLAN AVE
OSBURN ID
83849
US

IV. Provider business mailing address

805 E MULLAN AVE
OSBURN ID
83849
US

V. Phone/Fax

Practice location:
  • Phone: 208-556-1139
  • Fax:
Mailing address:
  • Phone: 208-556-1139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number13-02354489
License Number StateID

VIII. Authorized Official

Name: RON LAVIGNE
Title or Position: PRESIDENT
Credential:
Phone: 208-556-1139