Provider Demographics
NPI:1912423435
Name:POLSTON, ERIC SHANNON (PHARMD,DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:SHANNON
Last Name:POLSTON
Suffix:
Gender:M
Credentials:PHARMD,DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 LILY CREEK RESORT RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42629-7911
Mailing Address - Country:US
Mailing Address - Phone:270-343-4861
Mailing Address - Fax:
Practice Address - Street 1:43 MEDICAL LANE
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653
Practice Address - Country:US
Practice Address - Phone:606-376-1535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist