Healthcare Provider Details

I. General information

NPI: 1700188737
Provider Name (Legal Business Name): FREDS STORES OF TENNESSEE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2010
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W MAIN ST
EASLEY SC
29640-2038
US

IV. Provider business mailing address

4300 NEW GETWELL RD
MEMPHIS TN
38118-6801
US

V. Phone/Fax

Practice location:
  • Phone: 864-859-4015
  • Fax:
Mailing address:
  • Phone: 901-238-2520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number711227
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier711227
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 2
IdentifierDE3394
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerMEDICAID DME

VIII. Authorized Official

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