Provider Demographics
NPI:1407829369
Name:JASPER DRUGS LLC
Entity Type:Organization
Organization Name:JASPER DRUGS LLC
Other - Org Name:JASPER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
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 1:17 COURTHOUSE SQ
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347-3531
Mailing Address - Country:US
Mailing Address - Phone:423-942-5636
Mailing Address - Fax:423-942-1354
Practice Address - Street 1:17 COURTHOUSE SQ
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3531
Practice Address - Country:US
Practice Address - Phone:423-942-5636
Practice Address - Fax:423-942-1354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336M0002X
TN04663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095593OtherPK
TN1452478Medicaid
TN1452478Medicaid