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
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	CF00005247	WA

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	2110202	OTHER		PK

General Provider Information

NPI Number	:	1679519110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED MEYER STORES INC

Provider Business Mailing Address
First Line	:	P.O. BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:	513-762-1092

Provider Business Practice Location Address
First Line	:	2811 W 10TH AVE
Second Line	:
City	:	KENNEWICK
State	:	WA
Zip	:	99336-3104
Country	:	US
Telephone Number	:	509-735-8733
Fax Number	:	509-735-8727

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	:	09/19/2025

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