Provider Demographics
NPI:1457417339
Name:RIVERSIDE PARK PHARMACY INC
Entity type:Organization
Organization Name:RIVERSIDE PARK PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:EUNHYE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-985-7230
Mailing Address - Street 1:11655 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-1021
Mailing Address - Country:US
Mailing Address - Phone:818-985-7230
Mailing Address - Fax:818-985-7281
Practice Address - Street 1:11655 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-1021
Practice Address - Country:US
Practice Address - Phone:818-985-7230
Practice Address - Fax:818-985-7281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY463713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA463710Medicaid
1992105OtherPK
CAPHA463710Medicaid