Provider Demographics
NPI:1033280409
Name:RIVERSIDE PHARMACY & COMPOUNDING
Entity Type:Organization
Organization Name:RIVERSIDE PHARMACY & COMPOUNDING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY NHUNG
Authorized Official - Middle Name:TUYET
Authorized Official - Last Name:LUU
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:951-343-1633
Mailing Address - Street 1:9448 MAGNOLIA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503
Mailing Address - Country:US
Mailing Address - Phone:951-343-1633
Mailing Address - Fax:951-343-1675
Practice Address - Street 1:9448 MAGNOLIA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503
Practice Address - Country:US
Practice Address - Phone:951-343-1633
Practice Address - Fax:951-343-1675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY467163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA467160Medicaid
5615060OtherNABP
5604480001Medicare ID - Type Unspecified