Provider Demographics
NPI:1518470970
Name:FREDS OF DONIPHAN INC
Entity type:Organization
Organization Name:FREDS OF DONIPHAN INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,AO
Authorized Official - Prefix:
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-996-5220
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-0337
Mailing Address - Country:US
Mailing Address - Phone:573-996-5220
Mailing Address - Fax:573-996-3790
Practice Address - Street 1:100 H&S DRIVE
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935
Practice Address - Country:US
Practice Address - Phone:573-996-5220
Practice Address - Fax:573-996-3790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20180060813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2173109OtherPK