Healthcare Provider Details

I. General information

NPI: 1336449941
Provider Name (Legal Business Name): HANS W FREDERICKSEN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 BASIN ST SW
EPHRATA WA
98823-2138
US

IV. Provider business mailing address

1150 BASIN ST SW
EPHRATA WA
98823-2138
US

V. Phone/Fax

Practice location:
  • Phone: 509-754-3567
  • Fax: 509-754-3837
Mailing address:
  • Phone: 509-754-3567
  • Fax: 509-754-3837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPH000016364
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: