Provider Demographics
NPI:1508280272
Name:RIDER PHARMACY GROUP
Entity Type:Organization
Organization Name:RIDER PHARMACY GROUP
Other - Org Name:RIDER PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SLATES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH,CDE
Authorized Official - Phone:304-366-2710
Mailing Address - Street 1:303 MERCHANT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-5213
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:304-366-3201
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIDER PHARMACY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3975174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0142252000Medicaid