Provider Demographics
NPI:1497398226
Name:FRICKS PHARMACY LLC
Entity Type:Organization
Organization Name:FRICKS PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PDM
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:JADE
Authorized Official - Last Name:FRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:615-483-8310
Mailing Address - Street 1:3068 RANNOCH MOOR DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-5598
Mailing Address - Country:US
Mailing Address - Phone:615-483-8310
Mailing Address - Fax:
Practice Address - Street 1:6472 HIGHWAY 90 UNIT B
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4526
Practice Address - Country:US
Practice Address - Phone:850-483-0363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-24
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No291U00000XLaboratoriesClinical Medical Laboratory
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105468400Medicaid