Provider Demographics
NPI:1184759623
Name:FREDERICK, LEROY J (PD)
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:J
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1789 GRAND ANSE HWY # B
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-7103
Mailing Address - Country:US
Mailing Address - Phone:337-667-6977
Mailing Address - Fax:
Practice Address - Street 1:1017 CECILIA BRIDGE HWY
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517
Practice Address - Country:US
Practice Address - Phone:337-667-6271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist