Provider Demographics
NPI:1407614274
Name:BUNDY, BRIAN (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BUNDY
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 1:201 MARCELL DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1364
Mailing Address - Country:US
Mailing Address - Phone:616-863-9376
Mailing Address - Fax:616-863-9402
Practice Address - Street 1:201 MARCELL DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1364
Practice Address - Country:US
Practice Address - Phone:616-863-9376
Practice Address - Fax:616-863-9402
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist