Provider Demographics
NPI:1194155812
Name:RIDER PHARMACY
Entity type:Organization
Organization Name:RIDER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAINTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-366-2710
Mailing Address - Street 1:303 MERCHANT ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-5213
Mailing Address - Country:US
Mailing Address - Phone:304-366-2710
Mailing Address - Fax:304-366-0426
Practice Address - Street 1:303 MERCHANT ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-5213
Practice Address - Country:US
Practice Address - Phone:304-366-2710
Practice Address - Fax:304-366-0426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1467459545332B00000X
WV333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0142252000Medicaid
0427830001Medicare PIN