Provider Demographics
NPI:1902111743
Name:FREDERICK, RYAN (RPH)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:FREDERICK
Suffix:
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 1:800 W QUEEN CREEK RD
Mailing Address - Street 2:APT 2032
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-3300
Mailing Address - Country:US
Mailing Address - Phone:480-245-7694
Mailing Address - Fax:
Practice Address - Street 1:55 W APACHE TRL
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-3412
Practice Address - Country:US
Practice Address - Phone:480-288-1271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS010535183500000X
IN26021933A183500000X
OH03122846-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist