Healthcare Provider Details

I. General information

NPI: 1730460221
Provider Name (Legal Business Name): RIDLEY'S FAMILY MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 PINE AVE
KEMMERER WY
83101-3002
US

IV. Provider business mailing address

621 WASHINGTON ST S
TWIN FALLS ID
83301-5519
US

V. Phone/Fax

Practice location:
  • Phone: 307-877-4209
  • Fax: 307-877-6254
Mailing address:
  • Phone: 208-324-4633
  • Fax: 208-324-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberR10071
License Number StateWY

VIII. Authorized Official

Name: TODD WISE
Title or Position: PHARMACY COORDINATOR
Credential:
Phone: 801-358-3365