MEDICARE: FREDS STORES OF TENNESSEE INC

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	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295153518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDS STORES OF TENNESSEE INC

Provider Business Mailing Address
First Line	:	4300 NEW GETWELL RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38118-6801
Country	:	US
Telephone Number	:	901-238-2520
Fax Number	:	901-365-9820

Provider Business Practice Location Address
First Line	:	415 MOTT ST
Second Line	:
City	:	NEW MADRID
State	:	MO
Zip	:	63869-1955
Country	:	US
Telephone Number	:	573-748-5285
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	RICK CHAMBERS
Credential	:
Telephone Number	:	901-238-2477

Provider Enumeration Date	:	04/03/2014
Last Update Date	:	07/31/2014

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