Provider Demographics
NPI:1063822906
Name:RIDENOUR, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:RIDENOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3077 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45806-1466
Mailing Address - Country:US
Mailing Address - Phone:419-331-6410
Mailing Address - Fax:
Practice Address - Street 1:3298 ELIDA RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-1220
Practice Address - Country:US
Practice Address - Phone:419-331-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH032229661835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy