Provider Demographics
NPI:1710268222
Name:GUNDERSON, DANIELLE (PHARM D, MBA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:PHARM D, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MICHIGAN AVE W STE C
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MN
Mailing Address - Zip Code:56484-2274
Mailing Address - Country:US
Mailing Address - Phone:218-547-4734
Mailing Address - Fax:218-547-4523
Practice Address - Street 1:110 MICHIGAN AVE W STE C
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MN
Practice Address - Zip Code:56484-2274
Practice Address - Country:US
Practice Address - Phone:218-547-4734
Practice Address - Fax:218-547-4523
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0003715183500000X
MD18540183500000X
MN119285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist