1780616722 NPI number — FREDS STORES OF TENNESSEE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780616722 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:
1780616722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2007
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:
5050 PARKWAY DR STE 12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39211-4322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-957-0909
Provider Business Practice Location Address Fax Number:
601-957-9085
Provider Enumeration Date:
07/07/2006

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:  25841FJ , 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: 25841FJ , 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: 2517817 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0330114 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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