Provider Demographics
NPI:1720206774
Name:RIVERSIDE PHARMACY INC
Entity Type:Organization
Organization Name:RIVERSIDE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:HATFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:304-682-8132
Mailing Address - Street 1:PO BOX 431
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:WV
Mailing Address - Zip Code:25621-0431
Mailing Address - Country:US
Mailing Address - Phone:304-664-3343
Mailing Address - Fax:
Practice Address - Street 1:22 LARRY JOE HARLESS
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621
Practice Address - Country:US
Practice Address - Phone:304-664-3343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP0552340332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5989780001Medicare NSC