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	C3562	TN
2	3336C0003X	Community/Retail Pharmacy	C3562	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4434483	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1609808633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDS STORES OF TENNESSEE INC

Provider Business Mailing Address
First Line	:	6625 LENOX PARK BLVD.
Second Line	:	SUITE 200
City	:	MEMPHIS
State	:	TN
Zip	:	38115
Country	:	US
Telephone Number	:	901-238-2520
Fax Number	:	901-365-9820

Provider Business Practice Location Address
First Line	:	5897 E MAIN ST
Second Line	:
City	:	ERIN
State	:	TN
Zip	:	37061-4168
Country	:	US
Telephone Number	:	931-289-5995
Fax Number	:	931-289-5997

Authorized Official
Title or Position	:	SVP OF FINANCE
Name	:	RAHUL KULKARNI
Credential	:
Telephone Number	:	800-374-7417

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	12/06/2019

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