Provider Demographics
NPI:1033120613
Name:RIVER VALLEY PHCY AND SUPPLY LLC
Entity Type:Organization
Organization Name:RIVER VALLEY PHCY AND SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-968-2661
Mailing Address - Street 1:58 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-2104
Practice Address - Country:US
Practice Address - Phone:731-968-2661
Practice Address - Fax:731-968-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36383336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4434851OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN4434851Medicaid
TN4434851Medicaid