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	332B00000X	Durable Medical Equipment & Medical Supplies	02410/01.1	MS
2	3336C0003X	Community/Retail Pharmacy	02410/01.1	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2587446	OTHER		NCPDP

General Provider Information

NPI Number	:	1538313556
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	:	1467 HIGHWAY 1 S
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38701-7141
Country	:	US
Telephone Number	:	662-335-6060
Fax Number	:

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

Provider Enumeration Date	:	11/05/2008
Last Update Date	:	03/16/2009

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Directions to “FREDS STORES OF TENNESSEE INC ” Practice Location

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