Healthcare Provider Details

I. General information

NPI: 1114838547
Provider Name (Legal Business Name): MICAH RYDMAN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 N MAPLE GROVE RD
BOISE ID
83704-8239
US

IV. Provider business mailing address

286 N MAPLE GROVE RD
BOISE ID
83704-8239
US

V. Phone/Fax

Practice location:
  • Phone: 208-287-4667
  • Fax: 208-287-4668
Mailing address:
  • Phone: 208-287-4667
  • Fax: 208-287-4668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP6105
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: