Provider Demographics
NPI:1750661302
Name:FRIES, MARTIN
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:FRIES
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 1:2900 BOGGY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-9500
Mailing Address - Country:US
Mailing Address - Phone:407-344-4258
Mailing Address - Fax:
Practice Address - Street 1:2900 BOGGY CREEK RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-9500
Practice Address - Country:US
Practice Address - Phone:407-344-4258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS18757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist