Provider Demographics
NPI:1891001947
Name:FUNDERBURK, JASON (PHARMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FUNDERBURK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 S LAKESHORE DR
Mailing Address - Street 2:APT. 190
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7164
Mailing Address - Country:US
Mailing Address - Phone:215-292-2373
Mailing Address - Fax:
Practice Address - Street 1:6404 S MCCLINTOCK DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3942
Practice Address - Country:US
Practice Address - Phone:480-838-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS017925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist