Provider Demographics
NPI:1831482306
Name:STANS COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:STANS COMPOUNDING PHARMACY
Other - Org Name:STAN'S COMPOUNDING PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLFENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
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:423-775-3030
Mailing Address - Fax:423-775-6147
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:2011-05-17
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN00000005563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130891OtherPK
4444383OtherNCPDP PROVIDER IDENTIFICATION NUMBER