Provider Demographics
NPI:1043599897
Name:FREDERICK, JASON A (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:A
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 W CABELA DR
Mailing Address - Street 2:APT. 2338
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-1304
Mailing Address - Country:US
Mailing Address - Phone:330-240-0162
Mailing Address - Fax:
Practice Address - Street 1:5011 W UNION HILLS DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1441
Practice Address - Country:US
Practice Address - Phone:602-896-0257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018631183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist