Provider Demographics
NPI:1750064622
Name:MESA RIDGE, LLC
Entity type:Organization
Organization Name:MESA RIDGE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:435-668-8867
Mailing Address - Street 1:340 FALCON RIDGE PKWY STE 403
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-8851
Mailing Address - Country:US
Mailing Address - Phone:725-253-0103
Mailing Address - Fax:725-253-0104
Practice Address - Street 1:340 FALCON RIDGE PKWY STE 403
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-8851
Practice Address - Country:US
Practice Address - Phone:725-253-0103
Practice Address - Fax:725-253-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-08
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy