1114943784 NPI number — FREDS STORES OF TENNESSEE INC

Table of content: (NPI 1114943784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114943784 NPI number — FREDS STORES OF TENNESSEE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREDS STORES OF TENNESSEE 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:
Provider Other Organization Name Type Code:
6
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:
1114943784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4300 NEW GETWELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38118-6801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-238-2520
Provider Business Mailing Address Fax Number:
901-365-9820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
118 HUMPHREYS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ITTA BENA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38941-2004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-254-6241
Provider Business Practice Location Address Fax Number:
662-254-9907
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMBERS
Authorized Official First Name:
RICKY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
901-238-2477

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  0351201FI , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0351201FI , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0330269 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2518756 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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