Provider Demographics
NPI:1821187451
Name:SOUTH RIVER COMPOUNDING PHARMACY, INC
Entity Type:Organization
Organization Name:SOUTH RIVER COMPOUNDING PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:RICE
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:804-897-6447
Mailing Address - Street 1:11420 W HUGUENOT RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-1119
Mailing Address - Country:US
Mailing Address - Phone:804-897-6447
Mailing Address - Fax:804-897-6449
Practice Address - Street 1:11420 W HUGUENOT RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-1119
Practice Address - Country:US
Practice Address - Phone:804-897-6447
Practice Address - Fax:804-897-6449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8514585Medicaid