Healthcare Provider Details

I. General information

NPI: 1144875345
Provider Name (Legal Business Name): PETE RIDSDALE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1306
US

IV. Provider business mailing address

2516 GARDEN RD NE
RIO RANCHO NM
87124-2468
US

V. Phone/Fax

Practice location:
  • Phone: 505-688-4927
  • Fax:
Mailing address:
  • Phone: 505-688-4927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00005904
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: