Provider Demographics
NPI:1811352784
Name:RIVERA, LISA MARIE (RPH, CDE)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:RPH, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MALLARD CIR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4082
Mailing Address - Country:US
Mailing Address - Phone:817-269-7914
Mailing Address - Fax:
Practice Address - Street 1:1600 MALLARD CIR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4082
Practice Address - Country:US
Practice Address - Phone:817-269-7914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-20
Last Update Date:2015-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37451183500000X
FL32456183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist