Provider Demographics
NPI:1679863203
Name:BRUNGARDT, PAUL EDWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:EDWARD
Last Name:BRUNGARDT
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 1:4446 NW HODGES RD
Mailing Address - Street 2:
Mailing Address - City:SILVER LAKE
Mailing Address - State:KS
Mailing Address - Zip Code:66539-9203
Mailing Address - Country:US
Mailing Address - Phone:785-582-4449
Mailing Address - Fax:
Practice Address - Street 1:1401 SW WANAMAKER RD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-3869
Practice Address - Country:US
Practice Address - Phone:785-228-2672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-16
Last Update Date:2011-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS1-12620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist