Provider Demographics
NPI:1942257654
Name:FALLS RIVER PHARMACY, LLC
Entity Type:Organization
Organization Name:FALLS RIVER PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER-MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:III
Authorized Official - Credentials:RPH
Authorized Official - Phone:919-835-0457
Mailing Address - Street 1:10930 RAVEN RIDGE RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8725
Mailing Address - Country:US
Mailing Address - Phone:919-844-2055
Mailing Address - Fax:919-844-2054
Practice Address - Street 1:10930 RAVEN RIDGE RD
Practice Address - Street 2:SUITE 109
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8725
Practice Address - Country:US
Practice Address - Phone:919-844-2055
Practice Address - Fax:919-844-2054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9162332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7704396Medicaid
NC0920845Medicaid
NC3434987OtherNCPDP NUMBER
NC0920845Medicaid