Provider Demographics
NPI:1104166552
Name:RIVIERA DRUGS LLC
Entity type:Organization
Organization Name:RIVIERA DRUGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHALENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERUKURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-408-2937
Mailing Address - Street 1:8541 FORT SMALLWOOD RD STE G
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-2676
Mailing Address - Country:US
Mailing Address - Phone:410-255-1800
Mailing Address - Fax:410-255-1900
Practice Address - Street 1:8541 FORT SMALLWOOD RD
Practice Address - Street 2:UNIT G
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-2676
Practice Address - Country:US
Practice Address - Phone:410-255-1800
Practice Address - Fax:410-255-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP059413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139284OtherPK