Provider Demographics
NPI:1780671396
Name:RILEY, HEIDI (PHARMD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 N 2ND E
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:490 N 2ND E
Practice Address - Street 2:
Practice Address - City:MTN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2729
Practice Address - Country:US
Practice Address - Phone:208-587-3346
Practice Address - Fax:208-587-2052
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist