Provider Demographics
NPI:1710169396
Name:FREDRICKSON, ALIX (RPH)
Entity Type:Individual
Prefix:
First Name:ALIX
Middle Name:
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 NE 138TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-3409
Mailing Address - Country:US
Mailing Address - Phone:503-261-7541
Mailing Address - Fax:503-261-2048
Practice Address - Street 1:5717 NE 138TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-3409
Practice Address - Country:US
Practice Address - Phone:503-261-7541
Practice Address - Fax:503-261-2048
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 602258521835P2201X
OR92071835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care