Provider Demographics
NPI:1396813226
Name:STANDEFER, FRED JOEL JR (DPH)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:JOEL
Last Name:STANDEFER
Suffix:JR
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Mailing Address - Fax:
Practice Address - Street 1:3051 MAIN STREET
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN4735183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist