Provider Demographics
NPI:1376800367
Name:SUNRISE RX PHARMACY
Entity Type:Organization
Organization Name:SUNRISE RX PHARMACY
Other - Org Name:SUNRISE RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIER
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-288-7450
Mailing Address - Street 1:2336 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-3540
Mailing Address - Country:US
Mailing Address - Phone:239-288-7450
Mailing Address - Fax:239-288-7451
Practice Address - Street 1:2336 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-3540
Practice Address - Country:US
Practice Address - Phone:239-288-7450
Practice Address - Fax:239-288-7451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336M0002X
FLPH261513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135241OtherPK
FL006433900Medicaid