Provider Demographics
NPI:1871748012
Name:SUNNYSIDE DRUG
Entity type:Organization
Organization Name:SUNNYSIDE DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVIGNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-556-1139
Mailing Address - Street 1:805 E MULLAN AVE
Mailing Address - Street 2:
Mailing Address - City:OSBURN
Mailing Address - State:ID
Mailing Address - Zip Code:83849
Mailing Address - Country:US
Mailing Address - Phone:208-556-1139
Mailing Address - Fax:
Practice Address - Street 1:805 E MULLAN AVE
Practice Address - Street 2:
Practice Address - City:OSBURN
Practice Address - State:ID
Practice Address - Zip Code:83849
Practice Address - Country:US
Practice Address - Phone:208-556-1139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSBURN DRUG COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13-02354489332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies