Healthcare Provider Details

I. General information

NPI: 1124634555
Provider Name (Legal Business Name): RIVER VALLEY PRIMARY CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9755 W STATE HIGHWAY 22
RATCLIFF AR
72951-9000
US

IV. Provider business mailing address

PO BOX 130
RATCLIFF AR
72951-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-279-7709
  • Fax: 479-974-2044
Mailing address:
  • Phone: 479-279-7709
  • 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