1639107618 NPI number — FREDS STORES OF TENNESSEE INC

Table of content: (NPI 1639107618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639107618 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:
1639107618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2010
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:
1212 MILITARY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72015-2908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-778-2036
Provider Business Practice Location Address Fax Number:
501-778-6899
Provider Enumeration Date:
06/29/2006

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:  417255 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 417255 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 156772716 . This is a "DME" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 120515407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0417255 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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