Provider Demographics
NPI:1548329014
Name:SUNTREE PHARMACY
Entity type:Organization
Organization Name:SUNTREE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIAHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-253-3535
Mailing Address - Street 1:7640 N. WICKHAM RD #117
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940
Mailing Address - Country:US
Mailing Address - Phone:321-253-3535
Mailing Address - Fax:321-253-2522
Practice Address - Street 1:7640 N. WICKHAM RD #117
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940
Practice Address - Country:US
Practice Address - Phone:321-253-3535
Practice Address - Fax:321-253-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH18030183500000X
FL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH18030OtherPHARMACY LICENSE
FL000042400Medicaid
FL026219600Medicaid
FLBS7384174OtherDEA LICENSE
FLPH18030OtherPHARMACY LICENSE
FLBS7384174OtherDEA LICENSE