Provider Demographics
NPI:1093214728
Name:RIVERA, SALLY (RPH)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 CALLE VIENA
Mailing Address - Street 2:COLLEGE PARK IV
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921
Mailing Address - Country:US
Mailing Address - Phone:787-406-4411
Mailing Address - Fax:
Practice Address - Street 1:685 CALLE CESAR GONZALEZ
Practice Address - Street 2:WALGREENS PHARMACY
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-294-1730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist