Provider Demographics
NPI:1952685091
Name:RIDGE, KAYLEE ANNE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:ANNE
Last Name:RIDGE
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 S US HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5555 S US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4715
Practice Address - Country:US
Practice Address - Phone:812-299-2210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2022-02-10
Deactivation Date:2021-06-22
Deactivation Code:
Reactivation Date:2022-02-10
Provider Licenses
StateLicense IDTaxonomies
IN26024069A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist