Provider Demographics
NPI:1184050148
Name:RIDLEY'S FAMILY MARKETS, INC
Entity type:Organization
Organization Name:RIDLEY'S FAMILY MARKETS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KETTERLING
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM, D
Authorized Official - Phone:208-324-4633
Mailing Address - Street 1:621 WASHINGTON ST S
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5519
Mailing Address - Country:US
Mailing Address - Phone:208-233-4051
Mailing Address - Fax:208-233-2888
Practice Address - Street 1:1000 POCATELLO CREEK RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2926
Practice Address - Country:US
Practice Address - Phone:208-233-4051
Practice Address - Fax:208-233-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID22546RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID22546RPOtherSTATE LIC