Provider Demographics
NPI:1639779994
Name:RIVERA, MYRA Y (PHARMD)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:Y
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:Y
Other - Last Name:KELSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:136 HAPPY TRL
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-3025
Mailing Address - Country:US
Mailing Address - Phone:915-238-8600
Mailing Address - Fax:
Practice Address - Street 1:1209 S IH 35
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-5918
Practice Address - Country:US
Practice Address - Phone:830-629-9011
Practice Address - Fax:830-606-9186
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50422183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty