Provider Demographics
NPI:1023496056
Name:SUN, ANDREW WADE (PHARMD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:WADE
Last Name:SUN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 BOARDMAN DR
Mailing Address - Street 2:APT C18
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4774
Mailing Address - Country:US
Mailing Address - Phone:858-204-4738
Mailing Address - Fax:
Practice Address - Street 1:900 BOARDMAN DR
Practice Address - Street 2:APT C 18
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4774
Practice Address - Country:US
Practice Address - Phone:858-204-4738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008351183500000X
TX56250183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist