=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124389689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUN HEALTH AND WELLNESS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2012
-----------------------------------------------------
Last Update Date | 05/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 460 US HIGHWAY 17 92 N
-----------------------------------------------------
City | HAINES CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33844-4621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-422-4222
-----------------------------------------------------
Fax | 863-422-4290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 E HINSON AVE
-----------------------------------------------------
City | HAINES CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33844-5237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-438-2799
-----------------------------------------------------
Fax | 863-438-2770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BALA KODE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 863-438-2799
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH26157
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------