Provider Demographics
NPI:1649541715
Name:RIVERA, MIRIAM (RPH)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:RIVERA
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 1:6205 SUNNYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-1927
Mailing Address - Country:US
Mailing Address - Phone:757-420-1908
Mailing Address - Fax:
Practice Address - Street 1:115 W LITTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-2512
Practice Address - Country:US
Practice Address - Phone:757-489-5291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-22
Last Update Date:2012-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist