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	332B00000X	Durable Medical Equipment & Medical Supplies	PHRE009661	GA
2	3336C0003X	Community/Retail Pharmacy		GA

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	:	1922325281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDS STORES OF TENNESSEE INC

Provider Business Mailing Address
First Line	:	214 GA HIGHWAY 49 S
Second Line	:
City	:	BYRON
State	:	GA
Zip	:	31008-6937
Country	:	US
Telephone Number	:	478-956-0478
Fax Number	:	478-956-0281

Provider Business Practice Location Address
First Line	:	214 GA HIGHWAY 49 S
Second Line	:
City	:	BYRON
State	:	GA
Zip	:	31008-6937
Country	:	US
Telephone Number	:	478-956-0478
Fax Number	:	478-956-0281

Authorized Official
Title or Position	:	VP
Name	:	RICKY CHAMBERS
Credential	:	PHARMD
Telephone Number	:	901-238-2477

Provider Enumeration Date	:	04/27/2010
Last Update Date	:	08/09/2011

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Directions to “FREDS STORES OF TENNESSEE INC ” Practice Location

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