Provider Demographics
NPI:1659699494
Name:RIVER DRIVE PHARMACY LLC
Entity Type:Organization
Organization Name:RIVER DRIVE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-723-0265
Mailing Address - Street 1:223 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-1142
Mailing Address - Country:US
Mailing Address - Phone:606-723-0265
Mailing Address - Fax:
Practice Address - Street 1:223 RIVER DR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1142
Practice Address - Country:US
Practice Address - Phone:606-723-0265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP073943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100127260Medicaid