Provider Demographics
NPI:1891821310
Name:FREDERICK, TERRY ALLEN
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:ALLEN
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 1:1801 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JEANERETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70544-3423
Mailing Address - Country:US
Mailing Address - Phone:337-276-4101
Mailing Address - Fax:
Practice Address - Street 1:1801 MAIN ST
Practice Address - Street 2:
Practice Address - City:JEANERETTE
Practice Address - State:LA
Practice Address - Zip Code:70544-3423
Practice Address - Country:US
Practice Address - Phone:337-276-4101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1207624Medicaid
LA1906241OtherNABP NUMBER