Provider Demographics
NPI:1821380452
Name:ROCHE, LIVIA O
Entity Type:Individual
Prefix:
First Name:LIVIA
Middle Name:O
Last Name:ROCHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIVIA
Other - Middle Name:O
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 58183
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25358-0183
Mailing Address - Country:US
Mailing Address - Phone:304-550-6993
Mailing Address - Fax:
Practice Address - Street 1:333 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1263
Practice Address - Country:US
Practice Address - Phone:304-744-8362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV6724183500000X
FLPS-32479183500000X
PR4616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist