Provider Demographics
NPI:1376073890
Name:RIVERA, LUIS MANUEL
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:MANUEL
Last Name:RIVERA
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 2806
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-2806
Mailing Address - Country:US
Mailing Address - Phone:787-233-8928
Mailing Address - Fax:
Practice Address - Street 1:170 CALLE CAMBALACHE
Practice Address - Street 2:BO PAJAROS CANDELARIA
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:787-982-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001104183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1672759OtherDRIVER LICENCE