Provider Demographics
NPI:1073152245
Name:RUNDQUIST, ROGER ERIC (RPH)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ERIC
Last Name:RUNDQUIST
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 BLAINE AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1925
Mailing Address - Country:US
Mailing Address - Phone:815-289-1016
Mailing Address - Fax:
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-741-6980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-05
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15882-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist