Healthcare Provider Details

I. General information

NPI: 1679991236
Provider Name (Legal Business Name): FREDERIC PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 OAK ST W
FREDERIC WI
54837-8953
US

IV. Provider business mailing address

201 OAK ST W
FREDERIC WI
54837-8953
US

V. Phone/Fax

Practice location:
  • Phone: 715-327-4208
  • Fax: 715-327-4232
Mailing address:
  • Phone: 715-327-4208
  • Fax: 715-327-4232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number9306-42
License Number StateWI

VIII. Authorized Official

Name: ANITA LUNDQUIST
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 715-483-0260