Provider Demographics
NPI:1568642205
Name:SANDEFER, FREDERICK
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:SANDEFER
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 1:3355 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:DELEVAN
Mailing Address - State:NY
Mailing Address - Zip Code:14042-9530
Mailing Address - Country:US
Mailing Address - Phone:716-492-2346
Mailing Address - Fax:
Practice Address - Street 1:3355 GROVE ST
Practice Address - Street 2:
Practice Address - City:DELEVAN
Practice Address - State:NY
Practice Address - Zip Code:14042-9530
Practice Address - Country:US
Practice Address - Phone:716-492-2346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist