Healthcare Provider Details

I. General information

NPI: 1134430200
Provider Name (Legal Business Name): DR. TERRENCE M RIDLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DR. MARK T RIDLEY

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5007 VICTORY BLVD STE 2
TABB VA
23693-5606
US

IV. Provider business mailing address

5007 VICTORY BLVD STE 2
TABB VA
23693-5606
US

V. Phone/Fax

Practice location:
  • Phone: 757-234-7982
  • Fax:
Mailing address:
  • Phone: 757-234-7982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0202009903
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: