MEDICARE: SUNSET PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	PH 24933	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5704920	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1194024406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNSET PHARMACY LLC

Provider Business Mailing Address
First Line	:	4224 CLEVELAND AVE STE 5
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-9051
Country	:	US
Telephone Number	:	239-225-6337
Fax Number	:	239-437-6337

Provider Business Practice Location Address
First Line	:	4224 CLEVELAND AVE STE 5
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-9051
Country	:	US
Telephone Number	:	239-225-6337
Fax Number	:	239-437-6337

Authorized Official
Title or Position	:	PHARMACIST
Name	:	WALTER KLUKOWSKI
Credential	:
Telephone Number	:	239-225-6337

Provider Enumeration Date	:	03/25/2011
Last Update Date	:	03/30/2011

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Directions to “SUNSET PHARMACY LLC ” Practice Location

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