Provider Demographics
NPI:1730215070
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:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-358-3365
Mailing Address - Street 1:621 WASHINGTON ST. SOUTH
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 1:310 ONEIDA
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1756
Practice Address - Country:US
Practice Address - Phone:208-436-1200
Practice Address - Fax:208-436-6121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID807CP332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002633500Medicaid
ID002633500Medicaid