Provider Demographics
NPI:1629130752
Name:FREDERICK, ROBERT LYNN (DPH)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LYNN
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3435
Mailing Address - Country:US
Mailing Address - Phone:580-889-3331
Mailing Address - Fax:580-889-7765
Practice Address - Street 1:1002 W 13TH ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-3435
Practice Address - Country:US
Practice Address - Phone:580-889-3331
Practice Address - Fax:580-889-7765
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist