Provider Demographics
NPI:1952421729
Name:LUNDBERG, CHARLES (RPH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LUNDBERG
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 1:25 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-3707
Mailing Address - Country:US
Mailing Address - Phone:203-348-6823
Mailing Address - Fax:203-348-1231
Practice Address - Street 1:781 LYDIG AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-2144
Practice Address - Country:US
Practice Address - Phone:718-822-1348
Practice Address - Fax:718-822-1792
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033418183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist