Healthcare Provider Details

I. General information

NPI: 1144404641
Provider Name (Legal Business Name): RIDLEYS FAMILY MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 E GRAND AVE
LARAMIE WY
82070-5141
US

IV. Provider business mailing address

621 WASHINGTON ST S
TWIN FALLS ID
83301-5519
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-7246
  • Fax: 307-742-7392
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 NumberR10142
License Number StateWY

VIII. Authorized Official

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