Provider Demographics
NPI:1679280341
Name:GUNDRUM, PAIGE (PHARMD, BCPS)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:GUNDRUM
Suffix:
Gender:F
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6123
Mailing Address - Country:US
Mailing Address - Phone:608-843-9491
Mailing Address - Fax:
Practice Address - Street 1:420 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44131183500000X
WI22002-401835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No183500000XPharmacy Service ProvidersPharmacist