Provider Demographics
NPI:1407306046
Name:FREDERICK, BRENT (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:FREDERICK
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 1:5717 NE 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3409
Mailing Address - Country:US
Mailing Address - Phone:503-261-2000
Mailing Address - Fax:866-404-1777
Practice Address - Street 1:5717 NE 138TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-3409
Practice Address - Country:US
Practice Address - Phone:503-261-2000
Practice Address - Fax:866-404-1777
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00086501835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist