Provider Demographics
NPI:1801168034
Name:SUNSET PHARMACY LLC
Entity type:Organization
Organization Name:SUNSET PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTLAND
Authorized Official - Middle Name:
Authorized Official - Last Name:TWYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-225-6337
Mailing Address - Street 1:4224 CLEVELAND AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9051
Mailing Address - Country:US
Mailing Address - Phone:239-225-6337
Mailing Address - Fax:239-437-6337
Practice Address - Street 1:4224 CLEVELAND AVE STE 5
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9051
Practice Address - Country:US
Practice Address - Phone:239-225-6337
Practice Address - Fax:239-437-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
FLPH 249333336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5708966OtherNCPDP PROVIDER IDENTIFICATION NUMBER
FL003508600Medicaid