Provider Demographics
NPI:1144747411
Name:RIVER CITY PHARMACY INC
Entity Type:Organization
Organization Name:RIVER CITY PHARMACY INC
Other - Org Name:RIVER CITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:423-503-1243
Mailing Address - Street 1:5564 LITTLE DEBBIE PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-4356
Mailing Address - Country:US
Mailing Address - Phone:423-521-7279
Mailing Address - Fax:423-498-2480
Practice Address - Street 1:5564 LITTLE DEBBIE PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-4356
Practice Address - Country:US
Practice Address - Phone:423-521-7279
Practice Address - Fax:423-498-2480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-27
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TN60573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ035490Medicaid
2171095OtherPK