Provider Demographics
NPI:1396953303
Name:BUNDRICK, JOHN DANIEL (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DANIEL
Last Name:BUNDRICK
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 1:120 HICKORY KNOB HILL RD
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-9782
Mailing Address - Country:US
Mailing Address - Phone:803-749-1778
Mailing Address - Fax:803-933-8590
Practice Address - Street 1:1426 MAIN ST
Practice Address - Street 2:MC 11P
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-5804
Practice Address - Country:US
Practice Address - Phone:803-217-7068
Practice Address - Fax:803-217-9717
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC006311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist