=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982746327
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDS PHARMACY OF QUITMAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 01/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 MAIN ST
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39355-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-776-6282
-----------------------------------------------------
Fax | 601-776-6061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 MAIN ST
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39355-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-776-6282
-----------------------------------------------------
Fax | 601-776-6061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSING SPECIALIST
-----------------------------------------------------
Name | MS. JOYCE ROBERTSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-238-2520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 04508
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 04508
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------