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	3336C0004X	Compounding Pharmacy
2	3336L0003X	Long Term Care Pharmacy	PH 24933	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5708966	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801168034
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	:	FIRST FLOOR
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	:	MANING PARTNER
Name	:	COURTLAND TWYMAN
Credential	:
Telephone Number	:	239-225-6337

Provider Enumeration Date	:	02/03/2012
Last Update Date	:	03/20/2012

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Directions to “SUNSET PHARMACY LLC ” Practice Location

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