Provider Demographics
NPI:1023648847
Name:RIVERS STATE PHARMACY LLC
Entity type:Organization
Organization Name:RIVERS STATE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:XENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-363-3179
Mailing Address - Street 1:1919 AVENUE H STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-2629
Mailing Address - Country:US
Mailing Address - Phone:832-363-3179
Mailing Address - Fax:832-363-3634
Practice Address - Street 1:1919 AVENUE H STE 100
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-2629
Practice Address - Country:US
Practice Address - Phone:832-363-3179
Practice Address - Fax:832-363-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
01OtherCOMMERCIAL INSURANCE