Basic Information
| Provider Information | |||||||||
| NPI: | 1679563712 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVER VALLEY PRIMARY CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MULBERRY COMMUNITY PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | RATCLIFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794312057 | ||||||||
| FaxNumber: | 4794312058 | ||||||||
| Practice Location | |||||||||
| Address1: | 442 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MULBERRY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729478574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799978033 | ||||||||
| FaxNumber: | 4799971581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | JEROME | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4794312057 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 041036A | AR | Y | Suppliers | Pharmacy |
No ID Information.