Healthcare Provider Details

I. General information

NPI: 1225874944
Provider Name (Legal Business Name): NICHOLAS RIDENOUR PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 07/04/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 DIPLOMACY DR
ANCHORAGE AK
99508-5926
US

IV. Provider business mailing address

8740 CARTER CIR
ANCHORAGE AK
99507-3679
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-2130
  • Fax:
Mailing address:
  • Phone: 440-725-8245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03444274
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: