Healthcare Provider Details

I. General information

NPI: 1679291553
Provider Name (Legal Business Name): THOMAS B STANDEFER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E HIGHWAY 199
SPRINGTOWN TX
76082-2755
US

IV. Provider business mailing address

PO BOX 587
SPRINGTOWN TX
76082-0587
US

V. Phone/Fax

Practice location:
  • Phone: 817-220-1178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number27432
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: