Provider Demographics
NPI:1972968279
Name:NEW RIVER PHARMACY LLC
Entity Type:Organization
Organization Name:NEW RIVER PHARMACY LLC
Other - Org Name:MAIN STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COUNTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-605-7721
Mailing Address - Street 1:PO BOX 453
Mailing Address - Street 2:
Mailing Address - City:HAYSI
Mailing Address - State:VA
Mailing Address - Zip Code:24256-0453
Mailing Address - Country:US
Mailing Address - Phone:276-525-0198
Mailing Address - Fax:
Practice Address - Street 1:301 S MAIN ST STE 107
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-4978
Practice Address - Country:US
Practice Address - Phone:540-605-7721
Practice Address - Fax:540-605-7746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010046863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1972968279Medicaid
2157334OtherPK