Provider Demographics
NPI:1912306994
Name:FREDERICK, HARTSEL PAUL
Entity Type:Individual
Prefix:
First Name:HARTSEL
Middle Name:PAUL
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 1:5054 BENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-2051
Mailing Address - Country:US
Mailing Address - Phone:304-776-2789
Mailing Address - Fax:304-776-0787
Practice Address - Street 1:5054 BENNINGTON DR
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-2051
Practice Address - Country:US
Practice Address - Phone:304-776-2789
Practice Address - Fax:304-776-0787
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0003388183500000X
OH03113560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist