Provider Demographics
NPI:1285728329
Name:RIVER ROAD PHARMACY
Entity type:Organization
Organization Name:RIVER ROAD PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:COLQUITT
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:706-317-2583
Mailing Address - Street 1:5100 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5841
Mailing Address - Country:US
Mailing Address - Phone:706-317-2583
Mailing Address - Fax:706-317-2587
Practice Address - Street 1:5100 RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5841
Practice Address - Country:US
Practice Address - Phone:706-317-2583
Practice Address - Fax:706-317-2587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0087493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA434384249AMedicaid
GA5056990001Medicare NSC