Provider Demographics
NPI:1013299080
Name:FREDS STORES OF TENNESSEE INC.
Entity Type:Organization
Organization Name:FREDS STORES OF TENNESSEE INC.
Other - Org Name:FREDS PHARMACY #3748
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: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 1:306 LAMAR ST
Practice Address - Street 2:
Practice Address - City:KILMICHAEL
Practice Address - State:MS
Practice Address - Zip Code:39747-9732
Practice Address - Country:US
Practice Address - Phone:662-229-7874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-15
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09313333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06801260Medicaid
MS06801260Medicaid
MS512G730001Medicare PIN