Provider Demographics
NPI:1669753463
Name:RUNDBERG, DARYL PORTER (RPH)
Entity type:Individual
Prefix:MR
First Name:DARYL
Middle Name:PORTER
Last Name:RUNDBERG
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 1:5353 YELLOWSTONE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4178
Mailing Address - Country:US
Mailing Address - Phone:307-433-3679
Mailing Address - Fax:303-370-1692
Practice Address - Street 1:5353 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4178
Practice Address - Country:US
Practice Address - Phone:307-433-3679
Practice Address - Fax:303-370-1692
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2593183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist