Healthcare Provider Details

I. General information

NPI: 1669584587
Provider Name (Legal Business Name): RIVER VALLEY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 S ADAMS ST
SAINT CROIX FALLS WI
54024-9449
US

IV. Provider business mailing address

208 S ADAMS ST
SAINT CROIX FALLS WI
54024-9449
US

V. Phone/Fax

Practice location:
  • Phone: 715-483-0426
  • Fax:
Mailing address:
  • Phone: 715-483-0426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number7931042
License Number StateWI

VIII. Authorized Official

Name: DALE PERSZYK
Title or Position: MANAGER
Credential:
Phone: 715-483-0426