Provider Demographics
NPI:1942746672
Name:FRED MEYER STORES INC
Entity Type:Organization
Organization Name:FRED MEYER STORES INC
Other - Org Name:FRED MEYER PHARMACY #691
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF PHARMACY LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:MUENNICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-762-1263
Mailing Address - Street 1:PO BOX 842772
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-2772
Mailing Address - Country:US
Mailing Address - Phone:513-762-1019
Mailing Address - Fax:
Practice Address - Street 1:5502 POINT FOSDICK DR NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1725
Practice Address - Country:US
Practice Address - Phone:253-432-8830
Practice Address - Fax:253-432-8829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WAPHAR.CF.607312593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167328OtherPK