Provider Demographics
NPI:1245381094
Name:CHASTAINS INCORPORATED
Entity Type:Organization
Organization Name:CHASTAINS INCORPORATED
Other - Org Name:OWL SOUTHWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:AUER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-743-5528
Mailing Address - Street 1:720 16TH AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3768
Mailing Address - Country:US
Mailing Address - Phone:208-743-5528
Mailing Address - Fax:208-746-2785
Practice Address - Street 1:720 16TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3768
Practice Address - Country:US
Practice Address - Phone:208-743-5528
Practice Address - Fax:208-746-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID778RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6009963Medicaid
ID002248000Medicaid