Healthcare Provider Details

I. General information

NPI: 1922450196
Provider Name (Legal Business Name): RIDGE MANOR PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34490 CORTEZ BLVD
RIDGE MANOR FL
33523-8908
US

IV. Provider business mailing address

9603 ORANGE JASMINE WAY
TAMPA FL
33647-3020
US

V. Phone/Fax

Practice location:
  • Phone: 352-437-6851
  • Fax: 352-437-6852
Mailing address:
  • Phone: 813-304-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPH30189
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BASIM AHMED
Title or Position: OWNER
Credential:
Phone: 352-681-1988