Provider Demographics
NPI:1396584579
Name:RIVERA, NELSON G
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:G
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB DEL CARMEN F95 CALLE 6
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627
Mailing Address - Country:US
Mailing Address - Phone:939-402-6474
Mailing Address - Fax:
Practice Address - Street 1:WALMART PHARMACY 3716 STATE ROAD #2 KM 45.6
Practice Address - Street 2:PLAZA MONTE REAL
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-621-0487
Practice Address - Fax:787-621-0490
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11903183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician