Provider Demographics
NPI:1518999549
Name:FREDS STORES OF TENNESSEE INC
Entity Type:Organization
Organization Name:FREDS STORES OF TENNESSEE INC
Other - Org Name:FREDS PHARMACY 1571
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:KULKARNI
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 1:2415 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:TN
Practice Address - Zip Code:37062-9078
Practice Address - Country:US
Practice Address - Phone:615-799-0691
Practice Address - Fax:615-799-0692
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-07
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC1549333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4434750OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0537670184Medicare NSC
TN3538371Medicare PIN