MEDICARE: FRED'S PHARMACY #3958

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	E-010467	MS
2	183500000X	Pharmacist	PST.018472	LA

General Provider Information

NPI Number	:	1043688658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED'S PHARMACY #3958

Provider Business Mailing Address
First Line	:	303 N HOOD ST
Second Line	:
City	:	LAKE PROVIDENCE
State	:	LA
Zip	:	71254-2141
Country	:	US
Telephone Number	:	318-559-2433
Fax Number	:	318-559-2437

Provider Business Practice Location Address
First Line	:	303 N HOOD ST
Second Line	:
City	:	LAKE PROVIDENCE
State	:	LA
Zip	:	71254-2141
Country	:	US
Telephone Number	:	318-559-2433
Fax Number	:	318-559-2437

Authorized Official
Title or Position	:	PHARMACIST
Name	:	LAURA PERKINS
Credential	:
Telephone Number	:	318-559-2433

Provider Enumeration Date	:	09/14/2015
Last Update Date	:	09/14/2015

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