Provider Demographics
NPI:1780104067
Name:CRUZ RIVERA, ODALIS M
Entity type:Individual
Prefix:
First Name:ODALIS
Middle Name:M
Last Name:CRUZ RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3769 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-2937
Mailing Address - Country:US
Mailing Address - Phone:407-343-0357
Mailing Address - Fax:407-343-7754
Practice Address - Street 1:3769 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-2937
Practice Address - Country:US
Practice Address - Phone:407-343-0357
Practice Address - Fax:407-922-7754
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS62312183500000X
PR06477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist