Provider Demographics
NPI:1134430200
Name:RIDLEY, TERRENCE M
Entity type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:M
Last Name:RIDLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:T
Other - Last Name:RIDLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:340 ORIANA RD STE C
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-3645
Mailing Address - Country:US
Mailing Address - Phone:757-874-1924
Mailing Address - Fax:757-874-1084
Practice Address - Street 1:14260 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-3716
Practice Address - Country:US
Practice Address - Phone:757-874-1924
Practice Address - Fax:757-874-1084
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist