Provider Demographics
NPI:1659921450
Name:GUNDERSON, KELLY MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3036 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-2925
Mailing Address - Country:US
Mailing Address - Phone:515-576-7405
Mailing Address - Fax:
Practice Address - Street 1:3036 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-2925
Practice Address - Country:US
Practice Address - Phone:515-576-7405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-13
Last Update Date:2024-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22809183500000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist