Provider Demographics
NPI:1346228269
Name:FREDS SUPERMARKET AND PHARMACY OF THREE RIVERS INC
Entity Type:Organization
Organization Name:FREDS SUPERMARKET AND PHARMACY OF THREE RIVERS INC
Other - Org Name:FREDS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER STOCKHOLDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEROYL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:RPN
Authorized Official - Phone:269-278-2355
Mailing Address - Street 1:808 W MICHIGAN AVE
Mailing Address - Street 2:FREDS PHARMACY
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-3103
Mailing Address - Country:US
Mailing Address - Phone:269-278-2355
Mailing Address - Fax:269-279-9180
Practice Address - Street 1:808 W MICHIGAN AVE
Practice Address - Street 2:FREDS PHARMACY
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-3103
Practice Address - Country:US
Practice Address - Phone:269-278-2355
Practice Address - Fax:269-279-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010018173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2542203Medicaid
2333780OtherNABP
0670550001Medicare ID - Type UnspecifiedTYPE B