MEDICARE: MR. GARY WAYNE PUNDT R.PH.

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	115189-3	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	115189-3	OTHER	MN	MN BOARD OF PHARMACY LIC.

General Provider Information

NPI Number	:	1689664617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY WAYNE PUNDT R.PH.

Provider Business Mailing Address
First Line	:	202 N BROADWAY
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55906-3646
Country	:	US
Telephone Number	:	507-288-6463
Fax Number	:	507-288-2192

Provider Business Practice Location Address
First Line	:	202 N BROADWAY
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55906-3646
Country	:	US
Telephone Number	:	507-288-6463
Fax Number	:	507-288-2192

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

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	07/08/2007

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