Healthcare Provider Details

I. General information

NPI: 1295294551
Provider Name (Legal Business Name): KRISTIAN M. FREDRIKSEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2019
Last Update Date: 03/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

725 VALLEY RUN
HERCULES CA
94547-1445
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-1000
  • Fax:
Mailing address:
  • Phone: 510-253-6938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number79721
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: