Provider Demographics
NPI:1891052304
Name:RIVERA, NELLY L (PH)
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:L
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:J8 CALLE 3
Mailing Address - Street 2:VALPARAISO
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00949-4040
Mailing Address - Country:US
Mailing Address - Phone:787-784-8745
Mailing Address - Fax:
Practice Address - Street 1:CARR. #3, AVE. 65 DE INFANTERIA, INTERSEC CARR. #887
Practice Address - Street 2:BO. SAN ANTON
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00986-0858
Practice Address - Country:US
Practice Address - Phone:787-757-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2377183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist