Provider Demographics
NPI:1942896964
Name:RIVERA, PHILY LE
Entity Type:Individual
Prefix:
First Name:PHILY
Middle Name:LE
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 1:1145 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-1221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1145 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MA
Practice Address - Zip Code:01520-1221
Practice Address - Country:US
Practice Address - Phone:508-829-1780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH239942183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist