Provider Demographics
NPI:1104008739
Name:SANDERS, FRED (RPH)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:
Last Name:SANDERS
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 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:DUANE READE
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7606
Mailing Address - Country:US
Mailing Address - Phone:718-716-3143
Mailing Address - Fax:718-716-3568
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:DUANE READE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-716-3143
Practice Address - Fax:718-716-3568
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist