Provider Demographics
NPI:1083852586
Name:RIVERSIDE HEALTHCARE SERVICES INC
Entity Type:Organization
Organization Name:RIVERSIDE HEALTHCARE SERVICES INC
Other - Org Name:RIVERSIDE PHARMACY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-594-4600
Mailing Address - Street 1:608 DENBIGH BLVD
Mailing Address - Street 2:STE 800
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-4410
Mailing Address - Country:US
Mailing Address - Phone:757-875-7545
Mailing Address - Fax:757-875-7553
Practice Address - Street 1:848 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1303
Practice Address - Country:US
Practice Address - Phone:757-594-3944
Practice Address - Fax:757-534-6330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003424332BP3500X, 333600000X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4841777OtherNDPDP
VA1083852586Medicaid
VA4841777OtherNDPDP