Provider Demographics
NPI:1992054753
Name:BUNDY, JACQUELINE STIGALL (DPH)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:STIGALL
Last Name:BUNDY
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 MINERAL WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-4904
Mailing Address - Country:US
Mailing Address - Phone:731-644-1083
Mailing Address - Fax:731-644-0202
Practice Address - Street 1:1036 MINERAL WELLS AVE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4904
Practice Address - Country:US
Practice Address - Phone:731-644-1083
Practice Address - Fax:731-644-0202
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist