Basic Information
| Provider Information | |||||||||
| NPI: | 1205265808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | NEDA | ||||||||
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| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 E BETSY LN | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852964198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803707733 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 714 S VAL VISTA DR | ||||||||
| Address2: | FRY'S PHARMACY | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852963140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806549337 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 08/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | S020151 | AZ | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 53763 | TX | N | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 143925 | 05 | TX | MEDICAID |