Provider Demographics
NPI:1013201201
Name:RIVERA, WANDA A
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:A
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 1:7104 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-3124
Mailing Address - Country:US
Mailing Address - Phone:956-648-6199
Mailing Address - Fax:
Practice Address - Street 1:3600 W NOLANA AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-4594
Practice Address - Country:US
Practice Address - Phone:956-618-7701
Practice Address - Fax:956-618-7711
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-05
Last Update Date:2011-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist