Healthcare Provider Details

I. General information

NPI: 1609808633
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: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5897 E MAIN ST
ERIN TN
37061-4168
US

IV. Provider business mailing address

6625 LENOX PARK BLVD. SUITE 200
MEMPHIS TN
38115
US

V. Phone/Fax

Practice location:
  • Phone: 931-289-5995
  • Fax: 931-289-5997
Mailing address:
  • Phone: 901-238-2520
  • Fax: 901-365-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberC3562
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberC3562
License Number StateTN

VIII. Authorized Official

Name: RAHUL KULKARNI
Title or Position: SVP OF FINANCE
Credential:
Phone: 800-374-7417