Provider Demographics
NPI:1871073692
Name:FREDERICK, MARINA (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12171 BEACH BLVD APT 1726
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-1415
Mailing Address - Country:US
Mailing Address - Phone:850-225-4183
Mailing Address - Fax:
Practice Address - Street 1:2875 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2116
Practice Address - Country:US
Practice Address - Phone:904-730-7589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist