Provider Demographics
NPI:1518730852
Name:FREDRICH, MAXWELL TOD (PHARMD)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:TOD
Last Name:FREDRICH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 TIMBER RUN DR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1480
Mailing Address - Country:US
Mailing Address - Phone:920-574-0484
Mailing Address - Fax:
Practice Address - Street 1:1191 WESTOWNE DR
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2176
Practice Address - Country:US
Practice Address - Phone:920-725-3152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI22501-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program