MEDICARE: FREDS SUPER PHARMACY 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	183500000X	Pharmacist	5301003028	MI

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

General Provider Information

NPI Number	:	1902882426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDS SUPER PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 396
Second Line	:	131 N GRAND ST
City	:	SCHOOLCRAFT
State	:	MI
Zip	:	49087-0396
Country	:	US
Telephone Number	:	269-679-4061
Fax Number	:	269-679-4621

Provider Business Practice Location Address
First Line	:	131 N GRAND ST
Second Line	:
City	:	SCHOOLCRAFT
State	:	MI
Zip	:	49087
Country	:	US
Telephone Number	:	269-679-4061
Fax Number	:	269-679-4621

Authorized Official
Title or Position	:	PRESIDENT OWNER
Name	:	MR. FREDERICK WILLIAM NELSON
Credential	:	RPH
Telephone Number	:	269-649-0660

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	08/22/2020

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