Provider Demographics
NPI:1508253485
Name:BLUE RIVER HQ, LLC
Entity Type:Organization
Organization Name:BLUE RIVER HQ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHEMI
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:269-501-7034
Mailing Address - Street 1:1965 NEWMARK CIR SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32968-6711
Mailing Address - Country:US
Mailing Address - Phone:269-501-7034
Mailing Address - Fax:
Practice Address - Street 1:1394 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5732
Practice Address - Country:US
Practice Address - Phone:269-501-7034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-18
Last Update Date:2015-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy