Provider Demographics
NPI:1437753357
Name:FREDERICK, SHELLY (RPH)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6527 BRECKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-4858
Mailing Address - Country:US
Mailing Address - Phone:216-447-0990
Mailing Address - Fax:
Practice Address - Street 1:6527 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-4858
Practice Address - Country:US
Practice Address - Phone:216-447-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-318614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist