Healthcare Provider Details

I. General information

NPI: 1891909198
Provider Name (Legal Business Name): RIDLEYS FAMILY MARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 EAST PINE ST
PINEDALE WY
82941
US

IV. Provider business mailing address

621 WASHINGTON ST S
TWIN FALLS ID
83301-5519
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-4451
  • Fax: 307-367-6651
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 NumberR10037
License Number StateWY

VIII. Authorized Official

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