Provider Demographics
NPI:1275999013
Name:FAGEN, FREDERICK JOHN
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JOHN
Last Name:FAGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 W PEARL ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1843
Mailing Address - Country:US
Mailing Address - Phone:517-795-0507
Mailing Address - Fax:
Practice Address - Street 1:800 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2055
Practice Address - Country:US
Practice Address - Phone:517-278-5897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030328183500000X
IN26018579A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist