Healthcare Provider Details

I. General information

NPI: 1447485875
Provider Name (Legal Business Name): MAX BRADY STANDEFER DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 05/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4062 HIXSON PIKE
CHATTANOOGA TN
37415-3110
US

IV. Provider business mailing address

4062 HIXSON PIKE
CHATTANOOGA TN
37415-3110
US

V. Phone/Fax

Practice location:
  • Phone: 423-877-3568
  • Fax: 423-877-9332
Mailing address:
  • Phone: 423-877-3568
  • Fax: 423-877-9332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7335
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: