Provider Demographics
NPI:1730446923
Name:RIDGELAND APOTHECARY, LLC.
Entity type:Organization
Organization Name:RIDGELAND APOTHECARY, LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:CIALONE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:601-981-0070
Mailing Address - Street 1:500 HIGHWAY 51 NORTH
Mailing Address - Street 2:SUITE Q
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157
Mailing Address - Country:US
Mailing Address - Phone:601-981-0070
Mailing Address - Fax:601-981-4513
Practice Address - Street 1:500 HIGHWAY 51
Practice Address - Street 2:SUITE Q
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2599
Practice Address - Country:US
Practice Address - Phone:601-981-0070
Practice Address - Fax:601-981-4513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10816/1.13336C0003X, 3336C0003X
333600000X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
MS04085518Medicaid
2134701OtherPK
MS06588799Medicaid
6444360001Medicare NSC