Provider Demographics
NPI:1710956537
Name:RIVERSTONE PHARMACY
Entity Type:Organization
Organization Name:RIVERSTONE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PETRAROLI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-258-2294
Mailing Address - Street 1:101 RIVERSTONE VIS
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6648
Mailing Address - Country:US
Mailing Address - Phone:706-258-2294
Mailing Address - Fax:706-258-4149
Practice Address - Street 1:101 RIVERSTONE VIS
Practice Address - Street 2:SUITE 100
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6648
Practice Address - Country:US
Practice Address - Phone:706-258-2294
Practice Address - Fax:706-258-4149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008584333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00942719AMedicaid
1149500OtherNABP
1149500OtherNABP