Healthcare Provider Details

I. General information

NPI: 1336218288
Provider Name (Legal Business Name): RIVERSIDE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 GREEN ST NW
GAINESVILLE GA
30501-3325
US

IV. Provider business mailing address

935 GREEN ST NW
GAINESVILLE GA
30501-3325
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-6203
  • Fax: 770-532-3692
Mailing address:
  • Phone: 770-532-6203
  • Fax: 770-532-3692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE006669
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SCOTTIE BARTON
Title or Position: OWNER
Credential:
Phone: 770-532-6253