Provider Demographics
NPI:1780995357
Name:RYDER, RANDY A
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:A
Last Name:RYDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19205 HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-5413
Mailing Address - Country:US
Mailing Address - Phone:707-938-0282
Mailing Address - Fax:707-938-2649
Practice Address - Street 1:19205 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-5413
Practice Address - Country:US
Practice Address - Phone:707-938-0282
Practice Address - Fax:707-938-2649
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist