Basic Information
| Provider Information | |||||||||
| NPI: | 1922450196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIDGE MANOR PHARMACY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BENZER PHARMACY RIDGE MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9603 ORANGE JASMINE WAY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336473020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133042221 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 34490 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | RIDGE MANOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335238908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524376851 | ||||||||
| FaxNumber: | 3524376852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2016 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | AHMED | ||||||||
| AuthorizedOfficialFirstName: | BASIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3526811988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | PH30189 | FL | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 018722900 | 05 | FL | MEDICAID | 2160561 | 01 | PK | OTHER |