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	3336C0003X	Community/Retail Pharmacy	CF60114789	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	2121677	OTHER		PK

General Provider Information

NPI Number	:	1982836599
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED MEYER STORES INC.

Provider Business Mailing Address
First Line	:	PO BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-2772
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:	513-762-1092

Provider Business Practice Location Address
First Line	:	4550 42ND AVE SW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98116-4225
Country	:	US
Telephone Number	:	206-923-6391
Fax Number	:	206-923-6394

Authorized Official
Title or Position	:	MANAGER OF PHARMACY LICENSING
Name	:	ALLISON MUENNICH
Credential	:
Telephone Number	:	513-762-1019

Provider Enumeration Date	:	08/14/2009
Last Update Date	:	05/16/2016

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Directions to “FRED MEYER STORES INC. ” Practice Location

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