Provider Demographics
NPI:1538204532
Name:RIDGE MAUD DRUG CORPORATION
Entity type:Organization
Organization Name:RIDGE MAUD DRUG CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MICHEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MBA, CDE
Authorized Official - Phone:573-785-8218
Mailing Address - Street 1:910 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4242
Mailing Address - Country:US
Mailing Address - Phone:573-785-8218
Mailing Address - Fax:573-785-8125
Practice Address - Street 1:910 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4242
Practice Address - Country:US
Practice Address - Phone:573-785-8218
Practice Address - Fax:573-785-8125
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIDGE MAUD DRUG CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO620125609Medicaid
MO620125609Medicaid