Provider Demographics
NPI:1073289096
Name:SUNNYSIDE PEDIATRIC PHARMACY
Entity Type:Organization
Organization Name:SUNNYSIDE PEDIATRIC PHARMACY
Other - Org Name:SUNNYSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JEHU
Authorized Official - Middle Name:TOMAS
Authorized Official - Last Name:GRACIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-806-9100
Mailing Address - Street 1:13310 LEOPARD ST STE 28
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-4486
Mailing Address - Country:US
Mailing Address - Phone:361-248-4232
Mailing Address - Fax:361-248-4126
Practice Address - Street 1:13310 LEOPARD ST STE 28
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-4486
Practice Address - Country:US
Practice Address - Phone:361-248-4232
Practice Address - Fax:361-248-4126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-19
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy