Healthcare Provider Details

I. General information

NPI: 1467459545
Provider Name (Legal Business Name): RIDER PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 MERCHANT ST
FAIRMONT WV
26554-5213
US

IV. Provider business mailing address

303 MERCHANT STREET
FAIRMONT WV
26555-2138
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-2710
  • Fax: 304-366-3116
Mailing address:
  • Phone: 304-366-2710
  • Fax: 304-366-3201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberAR5100792
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN RIDER
Title or Position: OWNER
Credential:
Phone: 304-366-2710