Healthcare Provider Details

I. General information

NPI: 1093075145
Provider Name (Legal Business Name): RIVER STREET PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RIVER ST UNIT 203
SPRINGFIELD VT
05156-2930
US

IV. Provider business mailing address

100 RIVER ST UNIT 203
SPRINGFIELD VT
05156-2930
US

V. Phone/Fax

Practice location:
  • Phone: 802-885-6800
  • Fax: 802-885-6804
Mailing address:
  • Phone: 802-885-6800
  • Fax: 802-885-6804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number038.0087228
License Number StateVT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1021209
Identifier TypeMEDICAID
Identifier StateVT
Identifier Issuer
# 2
Identifier2135636
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: JASON HOCHBERG
Title or Position: OWNER
Credential:
Phone: 802-775-2545