Healthcare Provider Details

I. General information

NPI: 1023040961
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: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11299 HIGHWAY 63 S
LUCEDALE MS
39452-6617
US

IV. Provider business mailing address

4300 NEW GETWELL RD
MEMPHIS TN
38118-6801
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-8105
  • Fax: 601-947-1141
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 Number5031012
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5031012
License Number StateMS

VIII. Authorized Official

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