Provider Demographics
NPI:1013257070
Name:FRYE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FRYE
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 1:110 S 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 S 17TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4227
Practice Address - Country:US
Practice Address - Phone:715-848-9066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1485940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33275000Medicaid