Provider Demographics
NPI:1710263249
Name:FRIEDMAN, FRED GORDON (RPH)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:GORDON
Last Name:FRIEDMAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 ROSEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-5583
Mailing Address - Country:US
Mailing Address - Phone:651-636-6870
Mailing Address - Fax:
Practice Address - Street 1:2920 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1304
Practice Address - Country:US
Practice Address - Phone:651-251-9938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN011703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist