Provider Demographics
NPI:1295852770
Name:LUNDGREN, JEFFREY DANIEL SR (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DANIEL
Last Name:LUNDGREN
Suffix:SR
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 1:26739 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-3418
Mailing Address - Country:US
Mailing Address - Phone:847-526-5782
Mailing Address - Fax:
Practice Address - Street 1:384 E IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-2007
Practice Address - Country:US
Practice Address - Phone:630-529-3400
Practice Address - Fax:630-529-3429
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051034344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist