Provider Demographics
NPI:1306102470
Name:FREDS PHARMACY OF QUITMAN LLC
Entity type:Organization
Organization Name:FREDS PHARMACY OF QUITMAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-238-2477
Mailing Address - Street 1:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5105
Mailing Address - Country:US
Mailing Address - Phone:601-693-2655
Mailing Address - Fax:
Practice Address - Street 1:1123 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2959
Practice Address - Country:US
Practice Address - Phone:601-636-2756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDS PHARMACY OF QUITMAN LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-03
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04807541Medicaid
MS04807541Medicaid
MS1255890004Medicare NSC