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	AR20365	AR
2	3336C0003X	Community/Retail Pharmacy	AR20365	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0421797	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1205868239
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	:	901-238-2520
Fax Number	:	901-365-9820

Provider Business Practice Location Address
First Line	:	1110 E ANTIGO ST
Second Line	:
City	:	STAMPS
State	:	AR
Zip	:	71860-8850
Country	:	US
Telephone Number	:	870-533-4168
Fax Number	:	870-533-4296

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	:	03/07/2008

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