Healthcare Provider Details

I. General information

NPI: 1467766212
Provider Name (Legal Business Name): DOUG T WUNDERLICH PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 DEWEY ST
FOLEY MN
56329-8447
US

IV. Provider business mailing address

254 OAK DR PO BOX 160
FOLEY MN
56329-8725
US

V. Phone/Fax

Practice location:
  • Phone: 320-968-7272
  • Fax:
Mailing address:
  • Phone: 912-224-5211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number120155
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: