MEDICARE: FREDS STORES OF TENNESSEE 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	P06350	KY
2	3336C0003X	Community/Retail Pharmacy	P06350	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1825009	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093747032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDS STORES OF TENNESSEE INC

Provider Business Mailing Address
First Line	:	4300 NEW GETWELL RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38118-6801
Country	:	US
Telephone Number	:	980-123-8252
Fax Number	:	901-365-9820

Provider Business Practice Location Address
First Line	:	928 S 12TH ST
Second Line	:
City	:	MURRAY
State	:	KY
Zip	:	42071-2949
Country	:	US
Telephone Number	:	270-753-1272
Fax Number	:	270-759-5257

Authorized Official
Title or Position	:	VP
Name	:	RICKY CHAMBERS
Credential	:	PHARMD
Telephone Number	:	901-238-2477

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	08/02/2013

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