Provider Demographics
NPI:1114503331
Name:RIEVES, RYAN
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:RIEVES
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 1:1480 W ALWARD RD
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9784
Mailing Address - Country:US
Mailing Address - Phone:517-243-8931
Mailing Address - Fax:
Practice Address - Street 1:5110 TIMES SQUARE PL
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1161
Practice Address - Country:US
Practice Address - Phone:517-381-8267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303008397183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician