Healthcare Provider Details

I. General information

NPI: 1841236486
Provider Name (Legal Business Name): FRED MEYER STORES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 09/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GRANTS PASS PKWY
GRANTS PASS OR
97526-2333
US

IV. Provider business mailing address

P.O. BOX 842772
BOSTON MA
02284
US

V. Phone/Fax

Practice location:
  • Phone: 541-474-7234
  • Fax: 541-474-7240
Mailing address:
  • Phone: 513-762-1019
  • Fax: 513-762-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP0001052CS
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier211243
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier182554
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 3
Identifier2078033
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: ALLISON MUENNICH
Title or Position: MANAGER OF PHARMACY LICENSING
Credential:
Phone: 513-762-1019