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NPI Code Detail

MEDICARE: FRED MEYER STORES INC

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
1332B00000XDurable Medical Equipment & Medical Supplies
2333600000XPharmacy
33336C0003XCommunity/Retail PharmacyRP0001987CSOR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12079139OTHERPK
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1134165673
Entity Type Code : Organization
Provider Name (Legal Business Name) : FRED MEYER STORES INC
Provider Business Mailing Address
First Line : PO BOX 842772
Second Line :
City : BOSTON
State : MA
Zip : 02284-2772
Country : US
Telephone Number : 513-762-1019
Fax Number : 513-762-1092
Provider Business Practice Location Address
First Line : 22855 NE PARK LN
Second Line :
City : WOOD VILLAGE
State : OR
Zip : 97060-2606
Country : US
Telephone Number : 503-492-5033
Fax Number : 503-492-5027
Authorized Official
Title or Position : MANAGER OF PHARMACY LICENSING
Name : ALLISON MUENNICH
Credential :
Telephone Number : 513-762-1019
Provider Enumeration Date : 06/22/2006
Last Update Date : 06/29/2016

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