Provider Demographics
NPI:1588702120
Name:FREDERICKSON, CHARLOTTE ROSE (RPH)
Entity type:Individual
Prefix:MISS
First Name:CHARLOTTE
Middle Name:ROSE
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 OTTER POINT RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-7947
Mailing Address - Country:US
Mailing Address - Phone:850-484-7055
Mailing Address - Fax:
Practice Address - Street 1:1717 N E ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6339
Practice Address - Country:US
Practice Address - Phone:850-434-4549
Practice Address - Fax:850-434-4794
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS29588183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist