Provider Demographics
NPI:1083782221
Name:STANIFER PHARMACY LLC
Entity Type:Organization
Organization Name:STANIFER PHARMACY LLC
Other - Org Name:STANIFER DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ESSARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-626-7337
Mailing Address - Street 1:PO BOX 1438
Mailing Address - Street 2:
Mailing Address - City:NEW TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37824-1438
Mailing Address - Country:US
Mailing Address - Phone:423-626-7337
Mailing Address - Fax:423-626-0189
Practice Address - Street 1:420 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-6606
Practice Address - Country:US
Practice Address - Phone:423-626-7337
Practice Address - Fax:423-626-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TN40573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159557OtherPK
TN1454670Medicaid