Provider Demographics
NPI:1194868000
Name:RIVERS, JEFFREY WAYNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WAYNE
Last Name:RIVERS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4570 N PENN AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-5906
Mailing Address - Country:US
Mailing Address - Phone:620-331-3565
Mailing Address - Fax:
Practice Address - Street 1:601 W 11TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-5025
Practice Address - Country:US
Practice Address - Phone:620-251-1620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist