Provider Demographics
NPI:1447665807
Name:FREDS STORES OF TENNESSEE INC.
Entity type:Organization
Organization Name:FREDS STORES OF TENNESSEE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:
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 1:1603 RINGGOLD AVE
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019-9084
Practice Address - Country:US
Practice Address - Phone:318-932-5194
Practice Address - Fax:318-932-9507
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRED'S INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-24
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2202871Medicaid
LA2202871Medicaid