Provider Demographics
NPI:1194399485
Name:RIVERA AVILES, RANDY OMAR
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:OMAR
Last Name:RIVERA AVILES
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:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:ANASCO
Mailing Address - State:PR
Mailing Address - Zip Code:00610-0044
Mailing Address - Country:US
Mailing Address - Phone:787-826-4400
Mailing Address - Fax:
Practice Address - Street 1:17 CALLE SAN ANTONIO
Practice Address - Street 2:
Practice Address - City:ANASCO
Practice Address - State:PR
Practice Address - Zip Code:00610-2927
Practice Address - Country:US
Practice Address - Phone:787-826-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR006846183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist