Provider Demographics
NPI:1083794580
Name:COUNTY OF RIVERSIDE
Entity Type:Organization
Organization Name:COUNTY OF RIVERSIDE
Other - Org Name:RUHS-MC-RETAIL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:DAVALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:951-486-4529
Mailing Address - Street 1:26520 CACTUS AVE
Mailing Address - Street 2:DEPT OF PHARMACY
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3927
Mailing Address - Country:US
Mailing Address - Phone:951-486-4529
Mailing Address - Fax:951-486-4497
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-4529
Practice Address - Fax:951-486-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336M0002X, 3336S0011X
CAPHE435933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHOE435930Medicaid
2004687OtherPK