Provider Demographics
NPI:1669148011
Name:RIVAS, WALTER ANTONIO
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:ANTONIO
Last Name:RIVAS
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 1:24224 NORTHWEST FWY
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-5683
Mailing Address - Country:US
Mailing Address - Phone:281-758-1155
Mailing Address - Fax:
Practice Address - Street 1:24224 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-5683
Practice Address - Country:US
Practice Address - Phone:281-758-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist