Provider Demographics
NPI:1033155577
Name:FRED MEYER STORES INC
Entity Type:Organization
Organization Name:FRED MEYER STORES INC
Other - Org Name:FRED MEYER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF PHARMACY LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:LYSETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEILHAMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-762-1019
Mailing Address - Street 1:PO BOX 2918
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67504-2918
Mailing Address - Country:US
Mailing Address - Phone:513-762-1090
Mailing Address - Fax:513-762-1092
Practice Address - Street 1:5050 STATE HIGHWAY 303 NE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-3629
Practice Address - Country:US
Practice Address - Phone:360-792-2833
Practice Address - Fax:360-792-2792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WACF000038623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6008874Medicaid
2108820OtherPK
P00743921Medicare PIN
WA6008874Medicaid
2108820OtherPK