MEDICARE: ANDREA MUNDT PHARMD

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	26026767A	IN

General Provider Information

NPI Number	:	1942846019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA MUNDT PHARMD

Provider Business Mailing Address
First Line	:	5725 COVENTRY LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7146
Country	:	US
Telephone Number	:	260-432-2475
Fax Number	:	260-432-2494

Provider Business Practice Location Address
First Line	:	5725 COVENTRY LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7146
Country	:	US
Telephone Number	:	260-432-2475
Fax Number	:	260-432-2494

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

Provider Enumeration Date	:	11/22/2019
Last Update Date	:	11/22/2019

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