Provider Demographics
NPI:1013014935
Name:RIVERSIDE PHARMACY LLC
Entity Type:Organization
Organization Name:RIVERSIDE PHARMACY LLC
Other - Org Name:RIVERSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAYATHATHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-742-1188
Mailing Address - Street 1:540 RIVERSIDE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5352
Mailing Address - Country:US
Mailing Address - Phone:410-742-1188
Mailing Address - Fax:410-742-3408
Practice Address - Street 1:540 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5352
Practice Address - Country:US
Practice Address - Phone:410-742-1188
Practice Address - Fax:410-742-3408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP002963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2032824OtherPK
MD473628100Medicaid
MD040752600Medicaid
0562140001Medicare NSC