Provider Demographics
NPI:1548681877
Name:RIDLEYS FAMILY MARKETS INC
Entity type:Organization
Organization Name:RIDLEYS FAMILY MARKETS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-358-3365
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:208-324-4633
Mailing Address - Fax:208-324-1190
Practice Address - Street 1:4045 E PONY EXPRESS PKWY
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5512
Practice Address - Country:US
Practice Address - Phone:801-789-4997
Practice Address - Fax:801-789-4993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
UT871230517033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1548681877Medicaid
2143719OtherPK