Provider Demographics
NPI:1093301863
Name:RUNDE, CARISSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:RUNDE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 WOODEN SHOE RD
Mailing Address - Street 2:
Mailing Address - City:TEUTOPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62467-1203
Mailing Address - Country:US
Mailing Address - Phone:217-821-2971
Mailing Address - Fax:
Practice Address - Street 1:1316 CHARLESTON AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4016
Practice Address - Country:US
Practice Address - Phone:217-258-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.294331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist