Provider Demographics
NPI:1194497347
Name:RIVERA SERRANO, IVAN (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:RIVERA SERRANO
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BO . MONTICELLO
Mailing Address - Street 2:CARR 1 KM 56.5 INTERIOR
Mailing Address - City:CIDRA
Mailing Address - State:PR
Mailing Address - Zip Code:00739
Mailing Address - Country:US
Mailing Address - Phone:787-738-1444
Mailing Address - Fax:
Practice Address - Street 1:CARR 1 KM 56.5 MARGINAL, BO MONTELLANOS
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00737
Practice Address - Country:US
Practice Address - Phone:787-738-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist