Provider Demographics
NPI:1033759899
Name:FREDERICK, JERRY WALTER (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WALTER
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 1:4025 S OLD STATE ROAD 37
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7482
Mailing Address - Country:US
Mailing Address - Phone:812-824-5205
Mailing Address - Fax:
Practice Address - Street 1:4025 S OLD STATE ROAD 37
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7482
Practice Address - Country:US
Practice Address - Phone:812-824-5205
Practice Address - Fax:812-824-5207
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26012786A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist