MEDICARE: CHARLES LUNDBERG RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	033418	NY

General Provider Information

NPI Number	:	1952421729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES LUNDBERG RPH

Provider Business Mailing Address
First Line	:	25 HILLCREST AVE
Second Line	:
City	:	DARIEN
State	:	CT
Zip	:	06820-3707
Country	:	US
Telephone Number	:	203-348-6823
Fax Number	:	203-348-1231

Provider Business Practice Location Address
First Line	:	781 LYDIG AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10462-2144
Country	:	US
Telephone Number	:	718-822-1348
Fax Number	:	718-822-1792

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	07/08/2007

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