MEDICARE: FRED MEYER STORES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy	RP0000691CS	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2077728	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003852914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED MEYER STORES INC

Provider Business Mailing Address
First Line	:	P.O. BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:	513-762-1092

Provider Business Practice Location Address
First Line	:	650 Q ST
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-2353
Country	:	US
Telephone Number	:	541-741-5183
Fax Number	:	541-741-5180

Authorized Official
Title or Position	:	MANAGER OF PHARMACY LICENSING
Name	:	ALLISON MUENNICH
Credential	:
Telephone Number	:	513-762-1019

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	09/19/2025

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