Provider Demographics
NPI:1194052472
Name:LUNDBERG, GAYLE E (RPH)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:E
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PIMC-PNC PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-07
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18155183500000X
AZS014159183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist