Provider Demographics
NPI:1942934633
Name:SOUTH RIVER COMPOUNDING PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTH RIVER COMPOUNDING PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:PARKS
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:804-897-6447
Mailing Address - Street 1:3656 MAYLAND CT
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1409
Mailing Address - Country:US
Mailing Address - Phone:804-897-6447
Mailing Address - Fax:804-967-6449
Practice Address - Street 1:3656 MAYLAND CT
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1409
Practice Address - Country:US
Practice Address - Phone:804-897-6447
Practice Address - Fax:804-967-6449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-11
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy