Provider Demographics
NPI:1982680468
Name:FREDS SUPER PHARMACY INC
Entity Type:Organization
Organization Name:FREDS SUPER PHARMACY INC
Other - Org Name:FREDS VICKSBURG COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:OESTRIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-649-0660
Mailing Address - Street 1:PO BOX 80
Mailing Address - Street 2:121 W PRAIRIE ST
Mailing Address - City:VICKSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49097-0080
Mailing Address - Country:US
Mailing Address - Phone:269-649-0660
Mailing Address - Fax:269-649-4755
Practice Address - Street 1:121 W PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097
Practice Address - Country:US
Practice Address - Phone:269-649-0660
Practice Address - Fax:269-649-4755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010059833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3045857Medicaid
MI0755530002Medicare ID - Type Unspecified