Provider Demographics
NPI:1861037442
Name:RIDGE, SHANNON (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:RIDGE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:72 KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-8917
Mailing Address - Country:US
Mailing Address - Phone:910-546-2395
Mailing Address - Fax:
Practice Address - Street 1:1456 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-2736
Practice Address - Country:US
Practice Address - Phone:307-322-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY4183OtherWYOMING BOP PHARMACIST LICENSE