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Provider Information for 1295770725


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FRED MEYER STORES INC

Other Names:  
Doing Business As: 
FRED MEYER PHARMACY #653

Organization Subpart: NO

NPI: 1295770725
Last Updated: 2020-10-14
Certification Date: 2020-10-14

Details

NameValue
NPI1295770725
Enumeration Date2006-06-18
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: ALLISON MUENNICH
Title: MANAGER OF PHARMACY LICENSING
Phone: 5137621019
Mailing Address PO BOX 842772
BOSTON, MA 02284-2772
United States

Phone: 513-762-1019 | Fax:513-762-1092
 
Primary Practice Address 1501 E PARKS HWY
WASILLA, AK 99654-8283
United States

Phone: 907-352-5033 | Fax:907-352-5027
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDAK1021541
Other (non-Medicare)1996882PK
MEDICAIDAKPH0302
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 333600000X - Pharmacy
No 3336C0002X - Pharmacy - Clinic Pharmacy
No 332B00000X - Durable Medical Equipment & Medical Supplies
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyAKAK392