Provider Demographics
NPI:1104968098
Name:SUN LAKE DRUG
Entity type:Organization
Organization Name:SUN LAKE DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:NG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:323-662-1139
Mailing Address - Street 1:2860 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-2126
Mailing Address - Country:US
Mailing Address - Phone:323-662-1139
Mailing Address - Fax:323-663-1223
Practice Address - Street 1:2860 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-2126
Practice Address - Country:US
Practice Address - Phone:323-662-1139
Practice Address - Fax:323-663-1223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY19627333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA196270Medicaid