Provider Demographics
NPI:1053336693
Name:FRED MEYER STORES INC
Entity type:Organization
Organization Name:FRED MEYER STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERFACE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MINEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-387-7074
Mailing Address - Street 1:10116 NE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8532 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-3605
Practice Address - Country:US
Practice Address - Phone:206-297-8688
Practice Address - Fax:206-297-8760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WACF566573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6023220Medicaid
4927882OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0509530166Medicare NSC
WA6023220Medicaid