Healthcare Provider Details

I. General information

NPI: 1841222874
Provider Name (Legal Business Name): FREDS STORES OF TENNESSEE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 HIGHWAY 64 E
AUGUSTA AR
72006-9411
US

IV. Provider business mailing address

1302 HIGHWAY 64 E
AUGUSTA AR
72006-9411
US

V. Phone/Fax

Practice location:
  • Phone: 870-347-5004
  • Fax: 870-347-5014
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberAR20520
License Number StateAR

VIII. Authorized Official

Name: ALEX KNIGHT
Title or Position: DIR OF THIRD PARTY OPERATIONS
Credential:
Phone: 901-238-3625