Provider Demographics
NPI:1659780518
Name:SUNRISE PHARMACY LLC
Entity Type:Organization
Organization Name:SUNRISE PHARMACY LLC
Other - Org Name:LAUDERDALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUWOLE
Authorized Official - Middle Name:AYOTUNDE
Authorized Official - Last Name:OLUMIDE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:954-530-7171
Mailing Address - Street 1:4000 N STATE ROAD 7
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4804
Mailing Address - Country:US
Mailing Address - Phone:954-530-7171
Mailing Address - Fax:954-440-4180
Practice Address - Street 1:4000 N STATE ROAD 7
Practice Address - Street 2:SUITE 103
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-4804
Practice Address - Country:US
Practice Address - Phone:954-530-7171
Practice Address - Fax:954-440-4180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH283853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012965100Medicaid