Provider Demographics
NPI:1447873948
Name:FREDRICK, JOSEPH JACK (PHARMD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JACK
Last Name:FREDRICK
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 1:5757 N SHERIDAN RD APT 4D
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-8701
Mailing Address - Country:US
Mailing Address - Phone:773-970-2425
Mailing Address - Fax:
Practice Address - Street 1:17 W GOLF RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-2410
Practice Address - Country:US
Practice Address - Phone:847-296-5145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051298597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist