Provider Demographics
NPI:1467459545
Name:RIDER PHARMACY INC
Entity Type:Organization
Organization Name:RIDER PHARMACY INC
Other - Org Name:RIDER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-366-2710
Mailing Address - Street 1:303 MERCHANT STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26555-2138
Mailing Address - Country:US
Mailing Address - Phone:304-366-2710
Mailing Address - Fax:304-366-3201
Practice Address - Street 1:303 MERCHANT ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-5213
Practice Address - Country:US
Practice Address - Phone:304-366-2710
Practice Address - Fax:304-366-3116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAR5100792333600000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV014225200Medicaid
5001019OtherOTHER ID NUMBER
WV042783001Medicaid
WV042783001Medicaid