Provider Demographics
NPI:1467544601
Name:MUNDY, DWIGHT R (RPH)
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:R
Last Name:MUNDY
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 1:1289 13TH STREET WEST
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601
Mailing Address - Country:US
Mailing Address - Phone:701-225-5171
Mailing Address - Fax:
Practice Address - Street 1:16 WEST VILLARD
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-1073
Practice Address - Country:US
Practice Address - Phone:701-225-5171
Practice Address - Fax:701-225-1466
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3105183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist