Provider Demographics
NPI:1841255429
Name:SUNRISE MEDICAL PHARMACY
Entity type:Organization
Organization Name:SUNRISE MEDICAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-782-3137
Mailing Address - Street 1:6873 DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 SUNRISE AVE
Practice Address - Street 2:STE 1A
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7005
Practice Address - Country:US
Practice Address - Phone:916-782-3137
Practice Address - Fax:916-782-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336S0011X, 3336L0003X, 333600000X
CA0215623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0578166OtherOTHER ID NUMBER
0578166OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CAPHA413920Medicaid
CAPHA413920Medicaid