1912355231 NPI number — PAYLESS AT FRED'S INC

Table of content: (NPI 1912355231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912355231 NPI number — PAYLESS AT FRED'S INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAYLESS AT FRED'S INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PAYLESS AT FREDS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912355231
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 566
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARDMORE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38449-0429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-423-8969
Provider Business Mailing Address Fax Number:
256-423-8990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29930 ARDMORE AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARDMORE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35739-7450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-423-8989
Provider Business Practice Location Address Fax Number:
256-423-8990
Provider Enumeration Date:
05/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLAND
Authorized Official First Name:
NICK
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
256-423-2680

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 110617 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100002271 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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