Provider Demographics
NPI:1578698817
Name:FRIES, JEFFREY LEE
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
Last Name:FRIES
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 1:1019 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-1758
Mailing Address - Country:US
Mailing Address - Phone:563-582-4440
Mailing Address - Fax:563-584-3285
Practice Address - Street 1:1000 LANGWORTHY ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7313
Practice Address - Country:US
Practice Address - Phone:563-584-3405
Practice Address - Fax:563-584-3285
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16745183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist