Provider Demographics
NPI:1831999804
Name:RIVERSIDE PHARMACY 2 LLC
Entity type:Organization
Organization Name:RIVERSIDE PHARMACY 2 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:BALLENGEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:304-664-3343
Mailing Address - Street 1:PO BOX 431
Mailing Address - Street 2:22 LARRY JOE HARLESS DRIVE
Mailing Address - City:GILBERT
Mailing Address - State:WV
Mailing Address - Zip Code:25621
Mailing Address - Country:US
Mailing Address - Phone:304-664-3343
Mailing Address - Fax:304-664-8307
Practice Address - Street 1:22 LARRY JOE HARLESS DRIVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:WV
Practice Address - Zip Code:25621
Practice Address - Country:US
Practice Address - Phone:304-664-3343
Practice Address - Fax:304-664-8307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy