MEDICARE: SOUTH RIVER COMPOUNDING PHARMACY LLC

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	3336C0004X	Compounding Pharmacy

General Provider Information

NPI Number	:	1942934633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH RIVER COMPOUNDING PHARMACY LLC

Provider Business Mailing Address
First Line	:	3656 MAYLAND CT
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23233-1409
Country	:	US
Telephone Number	:	804-897-6447
Fax Number	:	804-967-6449

Provider Business Practice Location Address
First Line	:	3656 MAYLAND CT
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23233-1409
Country	:	US
Telephone Number	:	804-897-6447
Fax Number	:	804-967-6449

Authorized Official
Title or Position	:	PHARMACIST IN CHARGE
Name	:	JENNIFER PARKS HORN
Credential	:	RPH
Telephone Number	:	804-897-6447

Provider Enumeration Date	:	07/11/2022
Last Update Date	:	07/19/2022

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