Provider Demographics
NPI:1750767133
Name:RIVERA, JOHANNA STEPHANIE (PHARM D)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:STEPHANIE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:STEPHANIE
Other - Last Name:RIVERA ANAZAGASTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:112 E AMY DR
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589
Mailing Address - Country:US
Mailing Address - Phone:939-202-3579
Mailing Address - Fax:
Practice Address - Street 1:2106 TREASURE HILLS BLVD
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-8736
Practice Address - Country:US
Practice Address - Phone:956-366-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist