Provider Demographics
NPI:1457864266
Name:FRED'S OF DONIPHAN, INC
Entity Type:Organization
Organization Name:FRED'S OF DONIPHAN, INC
Other - Org Name:SUPER SAVER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-996-3953
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-0337
Mailing Address - Country:US
Mailing Address - Phone:573-996-3953
Mailing Address - Fax:
Practice Address - Street 1:100 H&S DRIVE
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935
Practice Address - Country:US
Practice Address - Phone:573-996-5220
Practice Address - Fax:573-996-3790
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRED'S OF DONIPHAN, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-15
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies