Provider Demographics
NPI:1619572781
Name:PINKSTON, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PINKSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 PINE TREE RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-9687
Mailing Address - Country:US
Mailing Address - Phone:409-540-9774
Mailing Address - Fax:
Practice Address - Street 1:4006 ESTES PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75603-1712
Practice Address - Country:US
Practice Address - Phone:903-234-2083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist