Provider Demographics
NPI:1942844584
Name:RIVERA-POLANCO, MARISEL
Entity Type:Individual
Prefix:
First Name:MARISEL
Middle Name:
Last Name:RIVERA-POLANCO
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 1:14818 FAVERSHAM CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4106
Mailing Address - Country:US
Mailing Address - Phone:407-405-4428
Mailing Address - Fax:
Practice Address - Street 1:9047 CURRY FORD RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-7604
Practice Address - Country:US
Practice Address - Phone:407-845-6530
Practice Address - Fax:407-845-6529
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS40398183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist