Provider Demographics
NPI:1861791055
Name:RIVERA, IVIS E
Entity type:Individual
Prefix:
First Name:IVIS
Middle Name:E
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 8297
Mailing Address - Street 2:
Mailing Address - City:COROZAL
Mailing Address - State:PR
Mailing Address - Zip Code:00783-6071
Mailing Address - Country:US
Mailing Address - Phone:787-693-0302
Mailing Address - Fax:787-693-0302
Practice Address - Street 1:URB MARIA DEL CARMEN
Practice Address - Street 2:CALLE 6 G 4
Practice Address - City:COROZAL
Practice Address - State:PR
Practice Address - Zip Code:00783
Practice Address - Country:US
Practice Address - Phone:787-693-0302
Practice Address - Fax:787-693-0302
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13-F-2931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist