Provider Demographics
NPI:1548812654
Name:FREDERICK, BRODY MICHAEL (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:BRODY
Middle Name:MICHAEL
Last Name:FREDERICK
Suffix:
Gender:M
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 1:40 THF BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1150
Mailing Address - Country:US
Mailing Address - Phone:636-536-6215
Mailing Address - Fax:
Practice Address - Street 1:40 THF BLVD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1150
Practice Address - Country:US
Practice Address - Phone:636-536-6215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019025927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist