1174051023 NPI number — FRED MEYER STORES INC

Table of content: (NPI 1174051023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174051023 NPI number — FRED MEYER STORES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRED MEYER STORES 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:
1174051023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1014 VINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45202-1141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-698-1878
Provider Business Mailing Address Fax Number:
513-698-1997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 NE 87TH AVE
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-882-2778
Provider Business Practice Location Address Fax Number:
360-975-7733
Provider Enumeration Date:
05/23/2017

Additional Information

Authorized Official

Authorized Official Last Name:
STONE
Authorized Official First Name:
KARLA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY CREDENTIALING MANAGER
Authorized Official Telephone Number:
513-698-1878

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: PHAR.CF.00057554 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2085027 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2169482 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com