Healthcare Provider Details

I. General information

NPI: 1306368352
Provider Name (Legal Business Name): FRED'S STORES OF TENNESSEE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13907 HIGH RD
MABELVALE AR
72103-3212
US

IV. Provider business mailing address

4300 NEW GETWELL RD
MEMPHIS TN
38118-6801
US

V. Phone/Fax

Practice location:
  • Phone: 501-455-1086
  • Fax: 501-455-4780
Mailing address:
  • Phone: 901-238-2520
  • Fax: 901-365-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOYCE ROBERTSON
Title or Position: RX LIC. & PERMITTING SPECIALIST
Credential:
Phone: 901-238-2520