Provider Demographics
NPI:1669584587
Name:RIVER VALLEY PHARMACY INC
Entity type:Organization
Organization Name:RIVER VALLEY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSZYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-483-0426
Mailing Address - Street 1:208 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-9449
Mailing Address - Country:US
Mailing Address - Phone:715-483-0426
Mailing Address - Fax:
Practice Address - Street 1:208 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-9449
Practice Address - Country:US
Practice Address - Phone:715-483-0426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X, 333600000X
WI79310423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5118509OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI33069300Medicaid