Provider Demographics
NPI:1164811402
Name:ASHTON MEMORIAL, INC
Entity Type:Organization
Organization Name:ASHTON MEMORIAL, INC
Other - Org Name:ASHTON COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-652-7461
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:ID
Mailing Address - Zip Code:83420-0838
Mailing Address - Country:US
Mailing Address - Phone:208-652-3932
Mailing Address - Fax:208-652-3470
Practice Address - Street 1:23 S. 8TH ST.
Practice Address - Street 2:
Practice Address - City:ASHTON
Practice Address - State:ID
Practice Address - Zip Code:83420
Practice Address - Country:US
Practice Address - Phone:208-652-3932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASHTON MEMORIAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-09
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1164811402Medicaid