Healthcare Provider Details

I. General information

NPI: 1366785701
Provider Name (Legal Business Name): SUNRISE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 07/10/2020
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 BERGENLINE AVE
WEST NEW YORK NJ
07093-5510
US

IV. Provider business mailing address

4911 BERGENLINE AVE
WEST NEW YORK NJ
07093-5510
US

V. Phone/Fax

Practice location:
  • Phone: 201-766-1900
  • Fax: 201-766-1904
Mailing address:
  • Phone: 201-766-1900
  • Fax: 201-766-1904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number StateNJ

VIII. Authorized Official

Name: MR. NEIL GODHANI
Title or Position: PRESIDENT
Credential:
Phone: 201-766-1900