Provider Demographics
NPI:1760794440
Name:RIVERSIDE SRX INC
Entity Type:Organization
Organization Name:RIVERSIDE SRX INC
Other - Org Name:RIVERSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VAMSIDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VASIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-491-5500
Mailing Address - Street 1:2920 FREDERICK DOUGLASS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039-1610
Mailing Address - Country:US
Mailing Address - Phone:212-491-5500
Mailing Address - Fax:212-491-5501
Practice Address - Street 1:2920 FREDERICK DOUGLASS BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039-1610
Practice Address - Country:US
Practice Address - Phone:212-491-5500
Practice Address - Fax:212-491-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0303843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5801724OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY6502290001Medicare NSC