Provider Demographics
NPI:1780036624
Name:FREDERICK, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-4206
Mailing Address - Country:US
Mailing Address - Phone:912-538-0311
Mailing Address - Fax:
Practice Address - Street 1:1108 E 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4206
Practice Address - Country:US
Practice Address - Phone:912-538-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-04
Last Update Date:2016-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029177183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist