Provider Demographics
NPI:1164134458
Name:RIVERA PEREZ, JEANNETTE
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:RIVERA PEREZ
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 1:4406 AVE MILITAR
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662-4158
Mailing Address - Country:US
Mailing Address - Phone:787-872-5943
Mailing Address - Fax:
Practice Address - Street 1:7032 AVE AGUSTIN RAMOS CALERO
Practice Address - Street 2:
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662-3432
Practice Address - Country:US
Practice Address - Phone:787-872-2860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR013700183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR013700Medicaid