Provider Demographics
NPI:1982746327
Name:FREDS PHARMACY OF QUITMAN
Entity Type:Organization
Organization Name:FREDS PHARMACY OF QUITMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-238-2520
Mailing Address - Street 1:125 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-2109
Mailing Address - Country:US
Mailing Address - Phone:601-776-6282
Mailing Address - Fax:601-776-6061
Practice Address - Street 1:125 MAIN ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-2109
Practice Address - Country:US
Practice Address - Phone:601-776-6282
Practice Address - Fax:601-776-6061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04508332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330475Medicaid
AL1982746327Medicaid
2521765OtherNCPDP
AL1982746327Medicaid
MS302G870981Medicare PIN