Provider Demographics
NPI:1336508308
Name:SUN PHARMACY, INC.
Entity Type:Organization
Organization Name:SUN PHARMACY, INC.
Other - Org Name:SUN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:LUU PHUONG
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:408-440-2077
Mailing Address - Street 1:2559 S KING RD
Mailing Address - Street 2:SUITE B10
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-1894
Mailing Address - Country:US
Mailing Address - Phone:408-440-2077
Mailing Address - Fax:408-677-3957
Practice Address - Street 1:2559 S KING RD
Practice Address - Street 2:SUITE B10
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-1894
Practice Address - Country:US
Practice Address - Phone:408-440-2077
Practice Address - Fax:408-677-3957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54368332B00000X, 332BX2000X
333600000X, 3336C0004X
CAPHY543683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1336508308Medicaid
2158484OtherPK