Provider Demographics
NPI:1578018008
Name:GUNDRUM, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GUNDRUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GERVAISE DR
Mailing Address - Street 2:
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-4606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 NASHUA RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3453
Practice Address - Country:US
Practice Address - Phone:603-437-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist