Provider Demographics
NPI:1477849370
Name:FONTENOT, DESHAWN D (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:DESHAWN
Middle Name:D
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5270 S STATE HIGHWAY 360
Mailing Address - Street 2:T-2243
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8307
Mailing Address - Country:US
Mailing Address - Phone:469-348-2101
Mailing Address - Fax:469-348-2104
Practice Address - Street 1:5270 S STATE HIGHWAY 360
Practice Address - Street 2:T-2243
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-8307
Practice Address - Country:US
Practice Address - Phone:469-348-2101
Practice Address - Fax:469-348-2104
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist