Provider Demographics
NPI:1538349352
Name:FREDERICK, LARRY ALAN JR (RPH)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:ALAN
Last Name:FREDERICK
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 SARATOGA RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4509
Mailing Address - Country:US
Mailing Address - Phone:518-387-3312
Mailing Address - Fax:518-387-3322
Practice Address - Street 1:204 SARATOGA RD.
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-3501
Practice Address - Country:US
Practice Address - Phone:518-387-3312
Practice Address - Fax:518-387-3322
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045302-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist