Provider Demographics
NPI:1679563712
Name:RIVER VALLEY PRIMARY CARE
Entity Type:Organization
Organization Name:RIVER VALLEY PRIMARY CARE
Other - Org Name:MULBERRY COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-431-2057
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951
Mailing Address - Country:US
Mailing Address - Phone:479-431-2057
Mailing Address - Fax:479-431-2058
Practice Address - Street 1:442 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:AR
Practice Address - Zip Code:72947-8574
Practice Address - Country:US
Practice Address - Phone:479-997-8033
Practice Address - Fax:479-997-1581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR041036A333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy