Provider Demographics
NPI:1477658797
Name:THREE RIVERS PHARMACY INC
Entity Type:Organization
Organization Name:THREE RIVERS PHARMACY INC
Other - Org Name:THREE RIVERS DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH.
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:BSPHARM
Authorized Official - Phone:559-561-4217
Mailing Address - Street 1:PO BOX 415
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:CA
Mailing Address - Zip Code:93271-0415
Mailing Address - Country:US
Mailing Address - Phone:559-561-4217
Mailing Address - Fax:
Practice Address - Street 1:40893 SIERRA DR
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:CA
Practice Address - Zip Code:93271-9583
Practice Address - Country:US
Practice Address - Phone:559-561-4217
Practice Address - Fax:559-561-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA515493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141848OtherPK
CAPHA19470Medicaid