MEDICARE: SUNRISE PHARMACY OF KISSIMMEE 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	3336C0003X	Community/Retail Pharmacy	30414	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2165964	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588107528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE PHARMACY OF KISSIMMEE LLC

Provider Business Mailing Address
First Line	:	4543 PLEASANT HILL RD STE D
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34759-3406
Country	:	US
Telephone Number	:	407-343-4434
Fax Number	:	407-343-4435

Provider Business Practice Location Address
First Line	:	4543 PLEASANT HILL RD STE D
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34759-3406
Country	:	US
Telephone Number	:	407-343-4434
Fax Number	:	407-343-4435

Authorized Official
Title or Position	:	MEMBER/MANAGER
Name	:	VAMSEE NALAGANDLA
Credential	:
Telephone Number	:	407-343-4434

Provider Enumeration Date	:	11/23/2016
Last Update Date	:	12/08/2018

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