Provider Demographics
NPI:1932197522
Name:UNDEBERG, MEGAN ROSINE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:ROSINE
Last Name:UNDEBERG
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 1:512 SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-3787
Mailing Address - Country:US
Mailing Address - Phone:218-878-7061
Mailing Address - Fax:218-878-7084
Practice Address - Street 1:512 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-3787
Practice Address - Country:US
Practice Address - Phone:218-878-7061
Practice Address - Fax:218-878-7084
Is Sole Proprietor?:No
Enumeration Date:2005-10-09
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA40087183500000X
MN119490183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN70-50447OtherMEDICA
MN217K8FAOtherBCBS OF MN
MN1932197522Medicaid