Provider Demographics
NPI:1497201255
Name:ASHTON, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ASHTON
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 1:12605 W LANKTREE GULCH RD
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5170
Mailing Address - Country:US
Mailing Address - Phone:208-514-8423
Mailing Address - Fax:208-288-4374
Practice Address - Street 1:3355 E LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5047
Practice Address - Country:US
Practice Address - Phone:208-288-4341
Practice Address - Fax:208-288-4374
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5987183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist