Provider Demographics
NPI: | 1598084121 |
---|---|
Name: | SUNDANCE INTERNATIONAL TRADING CO. |
Entity Type: | Organization |
Organization Name: | SUNDANCE INTERNATIONAL TRADING CO. |
Other - Org Name: | STONE DRUG |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LAURA |
Authorized Official - Middle Name: | LEE |
Authorized Official - Last Name: | NELSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | RPH |
Authorized Official - Phone: | 307-733-6222 |
Mailing Address - Street 1: | PO BOX 9000 |
Mailing Address - Street 2: | |
Mailing Address - City: | JACKSON |
Mailing Address - State: | WY |
Mailing Address - Zip Code: | 83002-9000 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 307-733-6222 |
Mailing Address - Fax: | 307-733-3528 |
Practice Address - Street 1: | 830 W BROADWAY |
Practice Address - Street 2: | |
Practice Address - City: | JACKSON |
Practice Address - State: | WY |
Practice Address - Zip Code: | 83001 |
Practice Address - Country: | US |
Practice Address - Phone: | 307-733-6222 |
Practice Address - Fax: | 307-733-3528 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-05-21 |
Last Update Date: | 2010-05-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WY | R10061 | 3336C0003X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy |