Provider Demographics
NPI:1114316940
Name:RIVER MEDICAL PHARMACY, LLC
Entity Type:Organization
Organization Name:RIVER MEDICAL PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:407-830-8820
Mailing Address - Street 1:4752 RESEARCH DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-5002
Mailing Address - Country:US
Mailing Address - Phone:800-617-1490
Mailing Address - Fax:844-557-5918
Practice Address - Street 1:4752 RESEARCH DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-5002
Practice Address - Country:US
Practice Address - Phone:800-617-1490
Practice Address - Fax:844-557-5918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147093Medicaid