Healthcare Provider Details

I. General information

NPI: 1033981725
Provider Name (Legal Business Name): JARED WUNDERLICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 19TH ST S # JT1728
BIRMINGHAM AL
35233-1900
US

IV. Provider business mailing address

619 19TH ST S # JT1728
BIRMINGHAM AL
35233-1900
US

V. Phone/Fax

Practice location:
  • Phone: 205-978-4317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15797
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: