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General NPI Number Information
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NPI Number | 1750064622
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Entity Type | Organization
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Legal Business Name | MESA RIDGE, LLC
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Dates
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Enumeration Date | 08/08/2023
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Last Update Date | 12/06/2023
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Provider Practice Location Address
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Address Line | 340 FALCON RIDGE PKWY STE 403
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City | MESQUITE
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State | NV
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Zip | 89027-8851
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Country | US
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Telephone | 725-253-0103
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Fax | 725-253-0104
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Provider Business Mailing Address
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Address Line | 340 FALCON RIDGE PKWY STE 403
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City | MESQUITE
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State | NV
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Zip | 89027-8851
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Country | US
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Telephone | 725-253-0103
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Fax | 725-253-0104
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | SAMUEL WILDE
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Credential | PHARMD
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Telephone | 435-668-8867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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