Provider Demographics
NPI:1922450196
Name:RIDGE MANOR PHARMACY
Entity Type:Organization
Organization Name:RIDGE MANOR PHARMACY
Other - Org Name:BENZER PHARMACY RIDGE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASIM
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-681-1988
Mailing Address - Street 1:9603 ORANGE JASMINE WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3020
Mailing Address - Country:US
Mailing Address - Phone:813-304-2221
Mailing Address - Fax:
Practice Address - Street 1:34490 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:RIDGE MANOR
Practice Address - State:FL
Practice Address - Zip Code:33523-8908
Practice Address - Country:US
Practice Address - Phone:352-437-6851
Practice Address - Fax:352-437-6852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH30189333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018722900Medicaid
2160561OtherPK