Provider Demographics
NPI:1043615842
Name:IENNA, FREDERICK (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:
Last Name:IENNA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-8087
Mailing Address - Country:US
Mailing Address - Phone:360-647-1611
Mailing Address - Fax:360-647-2316
Practice Address - Street 1:4420 MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8087
Practice Address - Country:US
Practice Address - Phone:360-647-1611
Practice Address - Fax:360-647-2316
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18381183500000X
WAPH60040384183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist