Provider Demographics
NPI:1376234823
Name:FREDERICKSEN, DANE (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DANE
Middle Name:
Last Name:FREDERICKSEN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6631 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2837
Mailing Address - Country:US
Mailing Address - Phone:714-757-7584
Mailing Address - Fax:
Practice Address - Street 1:2510 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1273
Practice Address - Country:US
Practice Address - Phone:760-729-8941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67972183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist