Healthcare Provider Details

I. General information

NPI: 1003942913
Provider Name (Legal Business Name): RIDLEY'S FAMILY MARKETS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MAIN ST. SOUTH
KIMBERLY ID
83341-0443
US

IV. Provider business mailing address

621 WASHINGTON ST. SOUTH
TWIN FALLS ID
83301-5519
US

V. Phone/Fax

Practice location:
  • Phone: 208-423-4248
  • Fax: 208-423-5767
Mailing address:
  • Phone: 208-324-4633
  • Fax: 208-324-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1730 CP
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1730CP
License Number StateID

VIII. Authorized Official

Name: DR. CATHI KETTERLING
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 208-324-4633