Provider Demographics
NPI:1821601592
Name:SPARKS, ASHTON BLAKE
Entity Type:Individual
Prefix:
First Name:ASHTON
Middle Name:BLAKE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PYRAMID DR APT 620
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-3269
Mailing Address - Country:US
Mailing Address - Phone:304-928-1914
Mailing Address - Fax:
Practice Address - Street 1:21 PYRAMID DR APT 620
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-3269
Practice Address - Country:US
Practice Address - Phone:304-928-1914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVIN0009753333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy