Provider Demographics
NPI:1205941234
Name:ASHLEY THOMPSON LLC
Entity type:Organization
Organization Name:ASHLEY THOMPSON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER LLC
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-524-8316
Mailing Address - Street 1:85 WESLEY DR
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-6033
Mailing Address - Country:US
Mailing Address - Phone:618-564-3115
Mailing Address - Fax:
Practice Address - Street 1:1001 E 5TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2311
Practice Address - Country:US
Practice Address - Phone:618-524-8316
Practice Address - Fax:618-524-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540159103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2017640OtherPK
2017640OtherPK