Provider Demographics
NPI:1225615727
Name:RIVERA, IRMA M
Entity Type:Individual
Prefix:
First Name:IRMA
Middle Name:M
Last Name:RIVERA
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 1:21 PATRIOT BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT BUCHANAN
Mailing Address - State:PR
Mailing Address - Zip Code:00934-4519
Mailing Address - Country:US
Mailing Address - Phone:787-707-2580
Mailing Address - Fax:
Practice Address - Street 1:21 PATRIOT BLVD
Practice Address - Street 2:
Practice Address - City:FORT BUCHANAN
Practice Address - State:PR
Practice Address - Zip Code:00934-4519
Practice Address - Country:US
Practice Address - Phone:787-707-2580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3169183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist