Provider Demographics
NPI:1255364881
Name:GOULD, FREDERICA A (RPH)
Entity type:Individual
Prefix:MS
First Name:FREDERICA
Middle Name:A
Last Name:GOULD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:TEDDIE
Other - Middle Name:
Other - Last Name:GOULD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1675 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:444 HOSPITAL WAY STE 801
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2792
Practice Address - Country:US
Practice Address - Phone:208-232-6214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4393183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist