MEDICARE: WHITE RIVER RURAL HEALTH CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0002X	Clinic Pharmacy
2	3336C0003X	Community/Retail Pharmacy	AR20585	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0422903	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1508021619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE RIVER RURAL HEALTH CENTER, INC.

Provider Business Mailing Address
First Line	:	623 N 9TH ST
Second Line	:
City	:	AUGUSTA
State	:	AR
Zip	:	72006-2129
Country	:	US
Telephone Number	:	870-347-2534
Fax Number	:	870-347-2882

Provider Business Practice Location Address
First Line	:	1009 HIGHWAY 18
Second Line	:	STE B
City	:	LAKE CITY
State	:	AR
Zip	:	72437-9622
Country	:	US
Telephone Number	:	870-237-1246
Fax Number	:	870-237-1248

Authorized Official
Title or Position	:	CEO
Name	:	STEVE COLLIER
Credential	:	MD
Telephone Number	:	870-347-3304

Provider Enumeration Date	:	07/29/2008
Last Update Date	:	08/07/2008

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