Provider Demographics
NPI:1851364483
Name:CATES STREET PHARMACY LLC
Entity type:Organization
Organization Name:CATES STREET PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:STANDEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-877-3568
Mailing Address - Street 1:PO BOX 1685
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:TN
Mailing Address - Zip Code:37327-1685
Mailing Address - Country:US
Mailing Address - Phone:423-949-5722
Mailing Address - Fax:423-949-6176
Practice Address - Street 1:104 CATES ST
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:TN
Practice Address - Zip Code:37327-6093
Practice Address - Country:US
Practice Address - Phone:423-949-5722
Practice Address - Fax:423-949-6176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN000039673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2094085OtherPK
TNQ047238Medicaid
5202230001Medicare NSC