Provider Demographics
NPI:1689768145
Name:CHASTAINS INCORPORATED
Entity Type:Organization
Organization Name:CHASTAINS INCORPORATED
Other - Org Name:OWL CONTRACT PRESCRIPTION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:AUER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-746-6755
Mailing Address - Street 1:720 16TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3768
Mailing Address - Country:US
Mailing Address - Phone:208-746-6755
Mailing Address - Fax:208-746-6801
Practice Address - Street 1:720 16TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3768
Practice Address - Country:US
Practice Address - Phone:208-746-6755
Practice Address - Fax:208-746-6801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID883LS3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002247900Medicaid
WA6012967Medicaid