Provider Demographics
NPI:1104421056
Name:RIVENBARK, JANE GADDIS (RPH)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:GADDIS
Last Name:RIVENBARK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3258 WHITE OAK RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1428
Mailing Address - Country:US
Mailing Address - Phone:540-904-5033
Mailing Address - Fax:
Practice Address - Street 1:1022 HARDY RD
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2241
Practice Address - Country:US
Practice Address - Phone:540-345-9851
Practice Address - Fax:540-345-3679
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02020100471835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist