Provider Demographics
NPI:1508879503
Name:ANGELO, FRED S
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:S
Last Name:ANGELO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 HELEN ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3536
Mailing Address - Country:US
Mailing Address - Phone:304-723-6356
Mailing Address - Fax:
Practice Address - Street 1:501 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:WV
Practice Address - Zip Code:26034-1319
Practice Address - Country:US
Practice Address - Phone:304-387-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4010183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist