Provider Demographics
NPI:1700473550
Name:FREDERICKS, LARRY ALAN
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:ALAN
Last Name:FREDERICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:NAPPANEE
Mailing Address - State:IN
Mailing Address - Zip Code:46550-1152
Mailing Address - Country:US
Mailing Address - Phone:574-221-1029
Mailing Address - Fax:
Practice Address - Street 1:242 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:NAPPANEE
Practice Address - State:IN
Practice Address - Zip Code:46550-2319
Practice Address - Country:US
Practice Address - Phone:574-773-7873
Practice Address - Fax:574-773-3673
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013548A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist