Provider Demographics
NPI:1427041185
Name:FOX DRUG STORE INC
Entity Type:Organization
Organization Name:FOX DRUG STORE INC
Other - Org Name:SUNNYSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LUNNY
Authorized Official - Middle Name:RONNIE
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:559-896-1645
Mailing Address - Street 1:1939 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-3510
Mailing Address - Country:US
Mailing Address - Phone:559-896-1645
Mailing Address - Fax:559-896-3266
Practice Address - Street 1:1939 HIGH ST
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3510
Practice Address - Country:US
Practice Address - Phone:559-896-1645
Practice Address - Fax:559-896-3266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27764183500000X, 1835N1003X
CAPHY43450332B00000X, 332BC3200X, 332BP3500X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacyGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No1835N1003XPharmacy Service ProvidersPharmacistNutrition SupportGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY43450Medicaid
CAPHY43450Medicaid
CA6571480001Medicare NSC
CA5162340001Medicare ID - Type UnspecifiedCMS BILLING