Provider Demographics
NPI:1346578804
Name:RIVERA-MORALES, IVELISSE
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:RIVERA-MORALES
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 1:330 AVE LOS DOMINICOS # URB
Mailing Address - Street 2:CALLE 28 BLOQUE 19 # 4
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00957-6707
Mailing Address - Country:US
Mailing Address - Phone:787-450-4090
Mailing Address - Fax:
Practice Address - Street 1:330 AVE LOS DOMINICOS # URB
Practice Address - Street 2:CALLE 28 BLOQUE 19 # 4
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00957-6707
Practice Address - Country:US
Practice Address - Phone:787-450-4090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7943183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7949OtherPHARM TEC LIC