=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326806969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2024
-----------------------------------------------------
Last Update Date | 03/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 RIVERSIDE DR STE 1
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-5375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-742-1188
-----------------------------------------------------
Fax | 410-742-3408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 540 RIVERSIDE DR STE 1
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-5375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-742-1188
-----------------------------------------------------
Fax | 410-742-3408
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | SANJAY L RAYATHATHA
-----------------------------------------------------
Credential | PHARMACIST
-----------------------------------------------------
Telephone | 410-948-0554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------