Provider Demographics
NPI:1710250501
Name:RUNDBERG, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:RUNDBERG
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 1:2131 NEWMARK ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1219
Mailing Address - Country:US
Mailing Address - Phone:541-756-7561
Mailing Address - Fax:
Practice Address - Street 1:2131 NEWMARK ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1219
Practice Address - Country:US
Practice Address - Phone:541-756-7561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0010505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist