Provider Demographics
NPI:1265602494
Name:RIVERSIDE PROF. DRUG INC.
Entity type:Organization
Organization Name:RIVERSIDE PROF. DRUG INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HADDIX
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-676-3784
Mailing Address - Street 1:2801 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2901
Mailing Address - Country:US
Mailing Address - Phone:734-676-3784
Mailing Address - Fax:734-676-3793
Practice Address - Street 1:2801 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2901
Practice Address - Country:US
Practice Address - Phone:734-676-3784
Practice Address - Fax:734-676-3793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301003409332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies