Provider Demographics
NPI:1154413961
Name:FEDDES, PATRICE MICKI
Entity type:Individual
Prefix:
First Name:PATRICE
Middle Name:MICKI
Last Name:FEDDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BRECKENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:31329-4226
Mailing Address - Country:US
Mailing Address - Phone:912-754-6162
Mailing Address - Fax:
Practice Address - Street 1:911 E 65TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4412
Practice Address - Country:US
Practice Address - Phone:912-355-0122
Practice Address - Fax:912-355-6620
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016920183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA016920OtherST PHARMACY LICENSE