Freds Super Pharmacy Inc
Organization Active NPI Community/Retail Pharmacy · Vicksburg, MI
NPI 1982680468 · NPPES record last updated Apr 1, 2015
Key facts
- NPI
- 1982680468
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 5301005983 (MI)
- Legal business name
- FREDS SUPER PHARMACY INC
- Practice address
- 121 W Prairie St
Vicksburg, MI 49097 - Phone
- (269) 649-0660
- Fax
- (269) 649-4755
- NPI assigned
- Dec 16, 2005
- Organization subpart
- No
Authorized official
- Name
- Elaine Oestrike
- Title
- Manager/RPH
- Phone
- (269) 649-0660
Other NPIs on the same Medicare enrollment 1
Practitioners 4
-
Lawrence Frigo, RPH
-
Jodee Ann Nelson, CPHT
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20060711000059 | MI | Part B Supplier - Mass Immunization (Roster Biller Only) | 6002829231 |
1 other NPI on this enrollment Practice locations: Vicksburg, MI |
National Provider Directory
Locations
13326 N Boulevard St
Vicksburg, MI 49097
Phone (269) 649-2321
7520 E U Ave
Vicksburg, MI 49097
Phone (269) 649-0660
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | 5301005983 | MI | Yes |
Addresses
Primary practice location
121 W Prairie St
Vicksburg, MI 49097
Mailing address
PO Box 80
121 W Prairie St
Vicksburg, MI 49097-0080
Phone (269) 649-0660
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3045857 | Medicaid | MI |
Other names
- Freds Vicksburg Community Pharmacy
Other providers in Vicksburg, MI
- Kathy Fenton-Miller
- Evan Fitzgerald
- Jamie V Floyd
- Aaron C Ford
- Kenneth J Franklin
- Gerald Alan Friedman
- Lawrence Frigo
- Erin Gehrman
- Janet Marie Glaes
- Healthcare Midwest, PC
All providers in Vicksburg, MI · Community/Retail Pharmacy in Michigan
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 1, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.