Provider Demographics
NPI:1528287042
Name:FREDS PHARMACY OF QUITMAN LLC
Entity type:Organization
Organization Name:FREDS PHARMACY OF QUITMAN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:901-238-2477
Mailing Address - Street 1:626 22ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-6120
Mailing Address - Country:US
Mailing Address - Phone:601-701-0019
Mailing Address - Fax:601-693-2693
Practice Address - Street 1:626 22ND AVE S
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-6120
Practice Address - Country:US
Practice Address - Phone:601-701-0019
Practice Address - Fax:601-693-2693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07342332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00701261Medicaid
2586812OtherNCPDP
MS00701261Medicaid
1255890003Medicare NSC