Provider Demographics
NPI:1578938353
Name:LUNDSTAD, LANCE (RPH)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:LUNDSTAD
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:PO BOX 821
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-0821
Mailing Address - Country:US
Mailing Address - Phone:507-458-1217
Mailing Address - Fax:
Practice Address - Street 1:151 TYLER RD N
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-1865
Practice Address - Country:US
Practice Address - Phone:651-388-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-05
Last Update Date:2015-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119193183500000X
WI12304183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist