Provider Demographics
NPI:1679174825
Name:FREDERICK, THERESA B (RPH)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:B
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 NICKLAUS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:SD
Mailing Address - Zip Code:57212-6603
Mailing Address - Country:US
Mailing Address - Phone:605-881-4250
Mailing Address - Fax:
Practice Address - Street 1:2233 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-1731
Practice Address - Country:US
Practice Address - Phone:605-692-1858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR-5037183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist