Provider Demographics
NPI:1154429496
Name:SUNRISE MEDICAL PHARMACY
Entity type:Organization
Organization Name:SUNRISE MEDICAL PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:702-732-2334
Mailing Address - Street 1:3006 S MARYLAND PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2219
Mailing Address - Country:US
Mailing Address - Phone:702-732-2334
Mailing Address - Fax:702-369-3490
Practice Address - Street 1:3006 S MARYLAND PKWY STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2219
Practice Address - Country:US
Practice Address - Phone:702-732-2334
Practice Address - Fax:702-369-3490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2802008Medicaid
NV5071600001Medicare ID - Type Unspecified