Provider Demographics
NPI:1598042368
Name:RYDER, WALTER W JR (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:W
Last Name:RYDER
Suffix:JR
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 FORT WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-1908
Mailing Address - Country:US
Mailing Address - Phone:212-568-5511
Mailing Address - Fax:212-795-8146
Practice Address - Street 1:593 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-1908
Practice Address - Country:US
Practice Address - Phone:212-568-5511
Practice Address - Fax:212-795-8146
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01636548Medicaid