Provider Demographics
NPI:1881751154
Name:RIVERSIDE DISCOUNT PHARMACY
Entity type:Organization
Organization Name:RIVERSIDE DISCOUNT PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MUOMAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-732-9342
Mailing Address - Street 1:705 S GORDON RD
Mailing Address - Street 2:STE A
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 S GORDON RD
Practice Address - Street 2:STE A
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126
Practice Address - Country:US
Practice Address - Phone:770-732-9342
Practice Address - Fax:770-732-9347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GA0074013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1136933OtherOTHER ID NUMBER
GA00506965BMedicaid
1136933OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1136933OtherOTHER ID NUMBER