Provider Demographics
NPI:1679962229
Name:RIDGWAY, HEATHER
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:RIDGWAY
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:PO BOX 6434
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-6434
Mailing Address - Country:US
Mailing Address - Phone:843-810-8545
Mailing Address - Fax:
Practice Address - Street 1:111 ALTAMONT AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-5910
Practice Address - Country:US
Practice Address - Phone:843-810-8545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHI-017889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPHI-017889OtherDEPARTMENT OF HEALTH