Provider Demographics
NPI:1477544567
Name:FUNDUM, MARCELLA ELAINE (RPH)
Entity Type:Individual
Prefix:
First Name:MARCELLA
Middle Name:ELAINE
Last Name:FUNDUM
Suffix:
Gender:F
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 TAMARACK ST
Mailing Address - Street 2:
Mailing Address - City:LAURIUM
Mailing Address - State:MI
Mailing Address - Zip Code:49913-2113
Mailing Address - Country:US
Mailing Address - Phone:906-337-2871
Mailing Address - Fax:
Practice Address - Street 1:220 CALUMET ST
Practice Address - Street 2:
Practice Address - City:LAKE LINDEN
Practice Address - State:MI
Practice Address - Zip Code:49945-1310
Practice Address - Country:US
Practice Address - Phone:906-296-6341
Practice Address - Fax:906-296-9341
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI22181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist