Provider Demographics
NPI:1073671608
Name:STANDEFER PHARMACY
Entity Type:Organization
Organization Name:STANDEFER PHARMACY
Other - Org Name:STANDEFER DRUGCENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:STANDEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-447-2134
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37367-0150
Mailing Address - Country:US
Mailing Address - Phone:423-447-2134
Mailing Address - Fax:423-447-6330
Practice Address - Street 1:3051 MAIN ST
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37367-0150
Practice Address - Country:US
Practice Address - Phone:423-447-2134
Practice Address - Fax:423-447-6330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X, 3336M0002X
TN10693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095984OtherPK
TN3513097Medicaid
0128220001Medicare NSC