Provider Demographics
NPI:1851011373
Name:RIVAS, STEPHANIE NICOLE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:RIVAS
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 1:2183 RED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HORATIO
Mailing Address - State:AR
Mailing Address - Zip Code:71842-8949
Mailing Address - Country:US
Mailing Address - Phone:870-582-4322
Mailing Address - Fax:
Practice Address - Street 1:926 E COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-9400
Practice Address - Country:US
Practice Address - Phone:870-642-6921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD16296183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist