Provider Demographics
NPI:1336429596
Name:FREDERICK, CHRISTOPHER ROBERT
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:ROBERT
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 1:2313 S MOUNT PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-1811
Mailing Address - Country:US
Mailing Address - Phone:847-227-1174
Mailing Address - Fax:847-759-1887
Practice Address - Street 1:2313 S MOUNT PROSPECT RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-1811
Practice Address - Country:US
Practice Address - Phone:847-227-1174
Practice Address - Fax:847-759-1887
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.118780183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician