Provider Demographics
NPI:1659771665
Name:FREDS PHARMACY OF QUITMAN
Entity Type:Organization
Organization Name:FREDS PHARMACY OF QUITMAN
Other - Org Name:FREDS PHARMACY 7141
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-238-2477
Mailing Address - Street 1:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5105
Mailing Address - Country:US
Mailing Address - Phone:601-693-2655
Mailing Address - Fax:
Practice Address - Street 1:304 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MS
Practice Address - Zip Code:38921-2231
Practice Address - Country:US
Practice Address - Phone:662-647-5541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDS PHARMACY OF QUITMAN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-27
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS4485702Medicaid
MS4485702Medicaid