Provider Demographics
NPI:1104843671
Name:FREDS STORES OF TENNESSEE INC
Entity Type:Organization
Organization Name:FREDS STORES OF TENNESSEE INC
Other - Org Name:FREDS XPRESS 3516
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:901-238-2477
Mailing Address - Street 1:4300 NEW GETWELL RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-6801
Mailing Address - Country:US
Mailing Address - Phone:901-238-2520
Mailing Address - Fax:901-365-9820
Practice Address - Street 1:25 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BROOKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39739
Practice Address - Country:US
Practice Address - Phone:662-738-5878
Practice Address - Fax:662-738-4888
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5847012333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2521359OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS6301716Medicaid
MS6301716Medicaid