MEDICARE: SUN PHARMA 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	3336S0011X	Specialty Pharmacy
3	3336C0003X	Community/Retail Pharmacy	29858	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2149470	OTHER		PK

General Provider Information

NPI Number	:	1629462932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUN PHARMA LLC

Provider Business Mailing Address
First Line	:	2829 BABCOCK RD STE 120
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-6009
Country	:	US
Telephone Number	:	210-617-4311
Fax Number	:	210-617-4312

Provider Business Practice Location Address
First Line	:	2829 BABCOCK RD STE 120
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-6009
Country	:	US
Telephone Number	:	210-617-4311
Fax Number	:	210-617-4312

Authorized Official
Title or Position	:	OWNER / PIC
Name	:	GANGADHAR REVULURI
Credential	:
Telephone Number	:	910-574-3002

Provider Enumeration Date	:	03/25/2015
Last Update Date	:	07/21/2023

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Directions to “SUN PHARMA LLC ” Practice Location

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