Provider Demographics
NPI:1306483565
Name:STANDEFER, CYNTHIA ANN
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:STANDEFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DENVER TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3666
Mailing Address - Country:US
Mailing Address - Phone:817-781-9077
Mailing Address - Fax:
Practice Address - Street 1:501 E HIGHWAY 199
Practice Address - Street 2:
Practice Address - City:SPRINGTOWN
Practice Address - State:TX
Practice Address - Zip Code:76082-2755
Practice Address - Country:US
Practice Address - Phone:817-220-1178
Practice Address - Fax:817-220-3250
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist