Provider Demographics
NPI:1134349459
Name:RIVERA CORREA, DIANA (RPH)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:RIVERA CORREA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. EL MADRIGAL 610 CALLE CIPRES
Mailing Address - Street 2:
Mailing Address - City:PENUELAS
Mailing Address - State:PR
Mailing Address - Zip Code:00624
Mailing Address - Country:US
Mailing Address - Phone:787-836-7643
Mailing Address - Fax:
Practice Address - Street 1:SAN CRISTOBAL PLZ
Practice Address - Street 2:COTO LAUREL
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00780-2929
Practice Address - Country:US
Practice Address - Phone:787-848-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRNERIELIS1226Medicare ID - Type Unspecified