Healthcare Provider Details

I. General information

NPI: 1740212786
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: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 KIDSPEACE DR
BOWDON GA
30108-3449
US

IV. Provider business mailing address

4300 NEW GETWELL RD
MEMPHIS TN
38118-6801
US

V. Phone/Fax

Practice location:
  • Phone: 770-258-0158
  • Fax: 770-258-0156
Mailing address:
  • Phone: 901-238-2520
  • Fax: 901-365-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE008991
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE008991
License Number StateGA

VIII. Authorized Official

Name: RICKY CHAMBERS
Title or Position: VP
Credential: PHARMD
Phone: 901-238-2477