Healthcare Provider Details

I. General information

NPI: 1902882426
Provider Name (Legal Business Name): FREDS SUPER PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 N GRAND ST
SCHOOLCRAFT MI
49087
US

IV. Provider business mailing address

PO BOX 396 131 N GRAND ST
SCHOOLCRAFT MI
49087-0396
US

V. Phone/Fax

Practice location:
  • Phone: 269-679-4061
  • Fax: 269-679-4621
Mailing address:
  • Phone: 269-679-4061
  • Fax: 269-679-4621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5301003028
License Number StateMI

VIII. Authorized Official

Name: MR. FREDERICK WILLIAM NELSON
Title or Position: PRESIDENT OWNER
Credential: RPH
Phone: 269-649-0660