Healthcare Provider Details

I. General information

NPI: 1407829369
Provider Name (Legal Business Name): JASPER DRUGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 COURTHOUSE SQ
JASPER TN
37347-3531
US

IV. Provider business mailing address

17 COURTHOUSE SQ
JASPER TN
37347-3531
US

V. Phone/Fax

Practice location:
  • Phone: 423-942-5636
  • Fax: 423-942-1354
Mailing address:
  • Phone: 423-942-5636
  • Fax: 423-942-1354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0466
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: FRED STANDEFER
Title or Position: OWNER
Credential:
Phone: 423-447-2134