Basic Information
| Provider Information | |||||||||
| NPI: | 1700995453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.PH. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1544 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456011032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407751175 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17273 STATE ROUTE 104 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456018608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407731141 | ||||||||
| FaxNumber: | 7407727199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 03-1-11032 | OH | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 03-1-11032 | 01 | OH | PHARMACY LICENSE | OTHER |