Provider Demographics
NPI:1609949163
Name:RIVER VALLEY PRIMARY CARE
Entity Type:Organization
Organization Name:RIVER VALLEY PRIMARY CARE
Other - Org Name:MIDLAND DRUG, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-431-2057
Mailing Address - Street 1:4900 KELLEY HWY
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72904-5000
Mailing Address - Country:US
Mailing Address - Phone:479-783-0221
Mailing Address - Fax:479-783-8945
Practice Address - Street 1:4900 KELLEY HWY
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-5000
Practice Address - Country:US
Practice Address - Phone:479-783-0221
Practice Address - Fax:479-783-8945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR203923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100392407Medicaid
AR100392407Medicaid