Provider Demographics
NPI:1700188737
Name:FREDS STORES OF TENNESSEE INC
Entity Type:Organization
Organization Name:FREDS STORES OF TENNESSEE INC
Other - Org Name:FREDS PHARMACY 3608
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:901-238-2477
Mailing Address - Street 1:4300 NEW GETWELL RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-6801
Mailing Address - Country:US
Mailing Address - Phone:901-238-2520
Mailing Address - Fax:
Practice Address - Street 1:101 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-2038
Practice Address - Country:US
Practice Address - Phone:864-859-4015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-24
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC711227332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC711227Medicaid
SCDE3394OtherMEDICAID DME
SCDE3394OtherMEDICAID DME
SC711227Medicaid