Provider Demographics
NPI:1215014188
Name:RIDER DRUG INC
Entity Type:Organization
Organization Name:RIDER DRUG INC
Other - Org Name:RIDER DRUG INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHCST
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:660-665-4666
Mailing Address - Street 1:1207 S BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4528
Mailing Address - Country:US
Mailing Address - Phone:660-665-4666
Mailing Address - Fax:660-665-2257
Practice Address - Street 1:1207 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4528
Practice Address - Country:US
Practice Address - Phone:660-665-4666
Practice Address - Fax:660-665-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MO0042543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MORI600131510Medicaid
2049000OtherPK