Provider Demographics
NPI:1033245436
Name:RIDLEYS FAMILY MARKETS INC
Entity Type:Organization
Organization Name:RIDLEYS FAMILY MARKETS INC
Other - Org Name:RIDLEYS PHARMACY #8444
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DOC OF PHARMACY
Authorized Official - Phone:801-358-3365
Mailing Address - Street 1:621 WASHINGTON ST S
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5519
Mailing Address - Country:US
Mailing Address - Phone:208-324-4633
Mailing Address - Fax:208-324-1190
Practice Address - Street 1:652 E 1ST ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2200
Practice Address - Country:US
Practice Address - Phone:208-549-0172
Practice Address - Fax:208-549-1148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID1396RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2020817OtherPK
ID805328000Medicaid