Provider Demographics
NPI:1073641718
Name:SUNDANCE DRUG CORP
Entity Type:Organization
Organization Name:SUNDANCE DRUG CORP
Other - Org Name:SUNDANCE DRUG & LIQUOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-923-5890
Mailing Address - Street 1:PO BOX 6280
Mailing Address - Street 2:
Mailing Address - City:SNOWMASS VLG
Mailing Address - State:CO
Mailing Address - Zip Code:81615-6280
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:0016 KEARNS RD
Practice Address - Street 2:
Practice Address - City:SNOWMASS VLG
Practice Address - State:CO
Practice Address - Zip Code:81615
Practice Address - Country:US
Practice Address - Phone:970-923-5890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14-13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy