Provider Demographics
NPI:1003920158
Name:SUN DRUG INC
Entity Type:Organization
Organization Name:SUN DRUG INC
Other - Org Name:OAKDALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SALAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:FATTAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:651-735-2300
Mailing Address - Street 1:2730 STILLWATER RD
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55119
Mailing Address - Country:US
Mailing Address - Phone:651-735-2300
Mailing Address - Fax:651-735-2301
Practice Address - Street 1:2730 STILLWATER RD
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55119
Practice Address - Country:US
Practice Address - Phone:651-735-2300
Practice Address - Fax:651-735-2301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25992503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2402523OtherNABP
1222170001Medicare ID - Type Unspecified