Provider Demographics
NPI:1326065897
Name:FREDS STORES OF TENNESSEE INC
Entity Type:Organization
Organization Name:FREDS STORES OF TENNESSEE INC
Other - Org Name:FREDS XPRESS 3861
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RAHUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KUL KARNI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-374-7417
Mailing Address - Street 1:6625 LENOX PARK BLVD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115
Mailing Address - Country:US
Mailing Address - Phone:901-238-2520
Mailing Address - Fax:901-365-9820
Practice Address - Street 1:705 PLANK ROAD HWY 128
Practice Address - Street 2:
Practice Address - City:ST. JOSEPH
Practice Address - State:LA
Practice Address - Zip Code:71366
Practice Address - Country:US
Practice Address - Phone:318-766-4563
Practice Address - Fax:318-766-4522
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5000333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1269743Medicaid
1930850OtherOTHER ID NUMBER-COMMERCIAL NUMBER
LA5BD07Medicare PIN
1930850OtherOTHER ID NUMBER-COMMERCIAL NUMBER