Provider Demographics
NPI:1982632949
Name:FREDS STORES OF TENNESSEE INC
Entity Type:Organization
Organization Name:FREDS STORES OF TENNESSEE INC
Other - Org Name:FREDS PHARMACY 1064
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
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:901-365-9820
Practice Address - Street 1:757 W OAK ST
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-2734
Practice Address - Country:US
Practice Address - Phone:985-748-6536
Practice Address - Fax:985-748-7286
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-29
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA035139RC333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1270971Medicaid
1931131OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0537670226Medicare NSC
LA5BD07Medicare PIN