Provider Demographics
NPI:1093075145
Name:RIVER STREET PHARMACY INC
Entity Type:Organization
Organization Name:RIVER STREET PHARMACY INC
Other - Org Name:RIVER STREET PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOCHBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-775-2545
Mailing Address - Street 1:100 RIVER ST
Mailing Address - Street 2:UNIT 203
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2930
Mailing Address - Country:US
Mailing Address - Phone:802-885-6800
Mailing Address - Fax:802-885-6804
Practice Address - Street 1:100 RIVER ST
Practice Address - Street 2:UNIT 203
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-2930
Practice Address - Country:US
Practice Address - Phone:802-885-6800
Practice Address - Fax:802-885-6804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
VT038.00872283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1021209Medicaid
2135636OtherPK