Provider Demographics
NPI:1164024733
Name:PINKSTON, SHANETTE
Entity Type:Individual
Prefix:
First Name:SHANETTE
Middle Name:
Last Name:PINKSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANETTE
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4283 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3148
Mailing Address - Country:US
Mailing Address - Phone:318-336-8801
Mailing Address - Fax:
Practice Address - Street 1:4283 CARTER ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3148
Practice Address - Country:US
Practice Address - Phone:318-336-8801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.022884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist