Provider Demographics
NPI:1174051023
Name:FRED MEYER STORES INC
Entity type:Organization
Organization Name:FRED MEYER STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-698-1878
Mailing Address - Street 1:1014 VINE ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1141
Mailing Address - Country:US
Mailing Address - Phone:513-698-1878
Mailing Address - Fax:513-698-1997
Practice Address - Street 1:700 NE 87TH AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1913
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-975-7733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-23
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WAPHAR.CF.000575543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2085027Medicaid
2169482OtherPK