=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508932211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER BEND RETAIL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 06/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 904 GRAND CENTRAL AVENUE STE D
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26105-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-295-8505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 904 GRAND CENTRAL AVENUE STE D
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26105-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-295-8505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | MRS. SANDRA ALLYN SWACKHAMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-295-8505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------