Provider Demographics
NPI:1083214787
Name:FREDERICK, MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 VETERANS MEMORIAL PARKWAY
Mailing Address - Street 2:(PHARMACY)
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303
Mailing Address - Country:US
Mailing Address - Phone:636-925-1143
Mailing Address - Fax:
Practice Address - Street 1:2855 VETERANS MEMORIAL PARKWAY
Practice Address - Street 2:(PHARMACY)
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303
Practice Address - Country:US
Practice Address - Phone:636-925-1143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019024409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist