Provider Demographics
NPI:1710082177
Name:STANS PHARMACY INC
Entity Type:Organization
Organization Name:STANS PHARMACY INC
Other - Org Name:STANS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBURN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:423-775-3030
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-0309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7787 RHEA COUNTY HWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-5982
Practice Address - Country:US
Practice Address - Phone:423-775-3030
Practice Address - Fax:423-775-6147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TN00000005563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452925Medicaid
4405913OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TN1452925Medicaid