Provider Demographics
NPI:1982761706
Name:RIVERSIDE MOT PHARMACY INC
Entity Type:Organization
Organization Name:RIVERSIDE MOT PHARMACY INC
Other - Org Name:RIVERSIDE MOT PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO AND PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-532-6253
Mailing Address - Street 1:935-B GREEN ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:770-532-6253
Mailing Address - Fax:770-532-3692
Practice Address - Street 1:935-B GREEN ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-532-6253
Practice Address - Fax:770-532-3692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0088283336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA609612415AMedicaid
2015567OtherPK