Provider Demographics
NPI:1366785701
Name:SUNRISE WELLNESS
Entity type:Organization
Organization Name:SUNRISE WELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GODHANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-766-1900
Mailing Address - Street 1:4911 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-5510
Mailing Address - Country:US
Mailing Address - Phone:201-766-1900
Mailing Address - Fax:201-766-1904
Practice Address - Street 1:4911 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-5510
Practice Address - Country:US
Practice Address - Phone:201-766-1900
Practice Address - Fax:201-766-1904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3336S0011X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7214150001Medicare NSC