Provider Demographics
NPI:1285989830
Name:SUN PHARMACY INC
Entity type:Organization
Organization Name:SUN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAO
Authorized Official - Middle Name:
Authorized Official - Last Name:KUE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:763-561-0722
Mailing Address - Street 1:6350 BROOKLYN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429
Mailing Address - Country:US
Mailing Address - Phone:763-561-0722
Mailing Address - Fax:763-561-0723
Practice Address - Street 1:6350 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-2669
Practice Address - Country:US
Practice Address - Phone:763-561-0722
Practice Address - Fax:763-561-0723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MN2639203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1285989830Medicaid
2136261OtherPK
MN1285989830Medicaid