Provider Demographics
NPI:1285987628
Name:GUNDRUM, JASON R (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:R
Last Name:GUNDRUM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9201
Mailing Address - Country:US
Mailing Address - Phone:262-329-1600
Mailing Address - Fax:262-329-1601
Practice Address - Street 1:975 PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9201
Practice Address - Country:US
Practice Address - Phone:262-329-1600
Practice Address - Fax:262-329-1601
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14219-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist