Provider Demographics
NPI:1457644395
Name:PENA-RIVERA, IDALIDES (RPH)
Entity Type:Individual
Prefix:
First Name:IDALIDES
Middle Name:
Last Name:PENA-RIVERA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CALLE GOYCO
Mailing Address - Street 2:
Mailing Address - City:NAGUABO
Mailing Address - State:PR
Mailing Address - Zip Code:00718-2253
Mailing Address - Country:US
Mailing Address - Phone:787-313-4842
Mailing Address - Fax:
Practice Address - Street 1:105 CARR 31
Practice Address - Street 2:
Practice Address - City:NAGUABO
Practice Address - State:PR
Practice Address - Zip Code:00718-2123
Practice Address - Country:US
Practice Address - Phone:787-874-8200
Practice Address - Fax:787-874-8209
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist