Provider Demographics
NPI:1700995453
Name:FREDERICK, RANDALL STEVEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:STEVEN
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-1032
Mailing Address - Country:US
Mailing Address - Phone:740-775-1175
Mailing Address - Fax:
Practice Address - Street 1:17273 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8608
Practice Address - Country:US
Practice Address - Phone:740-773-1141
Practice Address - Fax:740-772-7199
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-11032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03-1-11032OtherPHARMACY LICENSE