Healthcare Provider Details

I. General information

NPI: 1164222113
Provider Name (Legal Business Name): RIVER VALLEY PRIMARY CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 HIGHWAY 282 SW
MOUNTAINBURG AR
72946-4308
US

IV. Provider business mailing address

PO BOX 130
RATCLIFF AR
72951-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-369-2086
  • Fax:
Mailing address:
  • Phone: 479-431-2057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEROME J WHITE
Title or Position: CEO
Credential:
Phone: 479-431-2057