Provider Demographics
NPI:1679593586
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:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
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 1:156 WILFORD ASH PKWY
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528
Practice Address - Country:US
Practice Address - Phone:706-219-3733
Practice Address - Fax:706-219-3739
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-20
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0090483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154385OtherNCPDP
0537670306Medicare NSC