Provider Demographics
NPI:1407140221
Name:FREDERICKS, CATHERINE ELIZABETH (PHARM D, RPH)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:ELIZABETH
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3570 HARDEN BLVD
Mailing Address - Street 2:T-1299
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-5928
Mailing Address - Country:US
Mailing Address - Phone:863-648-0512
Mailing Address - Fax:863-648-0512
Practice Address - Street 1:3570 HARDEN BLVD
Practice Address - Street 2:T-1299
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-5928
Practice Address - Country:US
Practice Address - Phone:863-648-0512
Practice Address - Fax:863-648-0512
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022376000Medicaid
FL1090478OtherNCPDP
FL1881616431OtherPHARMACY'S NPI