Provider Demographics
NPI:1780278408
Name:RIVAS, EUSTACIO JR
Entity type:Individual
Prefix:
First Name:EUSTACIO
Middle Name:
Last Name:RIVAS
Suffix:JR
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 1:1576 LOMALAND DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-4202
Mailing Address - Country:US
Mailing Address - Phone:915-595-0409
Mailing Address - Fax:
Practice Address - Street 1:14476 HORIZON BLVD STE J
Practice Address - Street 2:
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-8579
Practice Address - Country:US
Practice Address - Phone:915-852-8884
Practice Address - Fax:915-852-1727
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31961183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist