Provider Demographics
NPI:1891414777
Name:FREDERICK, DANIEL JAMES
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:FREDERICK
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 1:66 ADELAIDE ST APT 53
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-3155
Mailing Address - Country:US
Mailing Address - Phone:586-438-6272
Mailing Address - Fax:
Practice Address - Street 1:33333 6 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3265
Practice Address - Country:US
Practice Address - Phone:734-513-5078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5351011347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist