Healthcare Provider Details

I. General information

NPI: 1073671608
Provider Name (Legal Business Name): STANDEFER PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3051 MAIN ST
PIKEVILLE TN
37367-0150
US

IV. Provider business mailing address

PO BOX 150
PIKEVILLE TN
37367-0150
US

V. Phone/Fax

Practice location:
  • Phone: 423-447-2134
  • Fax: 423-447-6330
Mailing address:
  • Phone: 423-447-2134
  • Fax: 423-447-6330

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 TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1069
License Number StateTN

VIII. Authorized Official

Name: FRED STANDEFER
Title or Position: PARTNER AND PHARMACIST
Credential:
Phone: 423-447-2134