Provider Demographics
NPI:1740214311
Name:RIVERA, LIZETTE
Entity Type:Individual
Prefix:
First Name:LIZETTE
Middle Name:
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 1:103 CALLE GMO ESTEVES
Mailing Address - Street 2:
Mailing Address - City:JAYUYA
Mailing Address - State:PR
Mailing Address - Zip Code:00664-1457
Mailing Address - Country:US
Mailing Address - Phone:787-828-0755
Mailing Address - Fax:787-828-6908
Practice Address - Street 1:103GMO. ESTEVES ST
Practice Address - Street 2:
Practice Address - City:JAYUYA
Practice Address - State:PR
Practice Address - Zip Code:00664
Practice Address - Country:US
Practice Address - Phone:787-828-0755
Practice Address - Fax:787-828-6908
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3859183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRDF030809OtherASSMCA
PR20F2670OtherHEALTH DEPARTMENT
PR20F2670OtherHEALTH DEPARTMENT
PR4130500001Medicare ID - Type Unspecified