1912423435 NPI number — ERIC SHANNON POLSTON PHARMD,DO

Table of content: ERIC SHANNON POLSTON PHARMD,DO (NPI 1912423435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912423435 NPI number — ERIC SHANNON POLSTON PHARMD,DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLSTON
Provider First Name:
ERIC
Provider Middle Name:
SHANNON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD,DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912423435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
238 LILY CREEK RESORT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMESTOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42629-7911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-343-4861
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43 MEDICAL LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITLEY CITY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-376-1535
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  11944 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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