Provider Demographics
NPI:1346207925
Name:LUNDBERG, A BLAIR (RPH)
Entity Type:Individual
Prefix:MR
First Name:A
Middle Name:BLAIR
Last Name:LUNDBERG
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 1:34 EAST 4TH ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIUM
Mailing Address - State:PA
Mailing Address - Zip Code:15834
Mailing Address - Country:US
Mailing Address - Phone:814-486-2326
Mailing Address - Fax:814-486-1065
Practice Address - Street 1:34 EAST 4TH ST
Practice Address - Street 2:
Practice Address - City:EMPORIUM
Practice Address - State:PA
Practice Address - Zip Code:15834
Practice Address - Country:US
Practice Address - Phone:814-486-3310
Practice Address - Fax:814-486-0974
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP029059L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009393900002Medicaid
3989374OtherNCPDP
PA0009393900002Medicaid