Provider Demographics
NPI:1275351553
Name:RIVEST, ETHAN CHRISTOPER
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:CHRISTOPER
Last Name:RIVEST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16595 TURNER CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ST MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32040-2815
Mailing Address - Country:US
Mailing Address - Phone:904-228-4082
Mailing Address - Fax:
Practice Address - Street 1:7749 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-7657
Practice Address - Country:US
Practice Address - Phone:904-781-2509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS67746183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist