Provider Demographics
NPI:1124301320
Name:BALLARD, SHANTELLE S (PHARMACIST)
Entity type:Individual
Prefix:MRS
First Name:SHANTELLE
Middle Name:S
Last Name:BALLARD
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S FERN ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-2862
Mailing Address - Country:US
Mailing Address - Phone:703-413-7082
Mailing Address - Fax:703-413-7429
Practice Address - Street 1:1200 S FERN ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-2862
Practice Address - Country:US
Practice Address - Phone:703-413-7082
Practice Address - Fax:703-413-7429
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011132183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist