Provider Demographics
NPI:1245773803
Name:AUTENRIEB, FREDERICK BOYD (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:BOYD
Last Name:AUTENRIEB
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 1:795 JOAQUIN ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-3628
Mailing Address - Country:US
Mailing Address - Phone:530-257-8581
Mailing Address - Fax:
Practice Address - Street 1:795 JOAQUIN ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-3628
Practice Address - Country:US
Practice Address - Phone:530-257-8581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57145183500000X
VA0202206987183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A64390Medicare UPIN