Provider Demographics
NPI:1558381459
Name:RIVER NORTH PHARMACY
Entity Type:Organization
Organization Name:RIVER NORTH PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:715-479-4736
Mailing Address - Street 1:711-E HWY 45 NORTH
Mailing Address - Street 2:P.O. BOX 1477
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521
Mailing Address - Country:US
Mailing Address - Phone:715-479-4736
Mailing Address - Fax:715-479-1320
Practice Address - Street 1:711-E HWY 45 NORTH
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521
Practice Address - Country:US
Practice Address - Phone:715-479-4736
Practice Address - Fax:715-479-1320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11609183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33251400Medicaid
WI5105728OtherNABP OR PCPDP NUMBER
WI5105728OtherNABP OR PCPDP NUMBER