Healthcare Provider Details

I. General information

NPI: 1851011373
Provider Name (Legal Business Name): STEPHANIE NICOLE RIVAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 E COLLIN RAYE DR
DE QUEEN AR
71832-9400
US

IV. Provider business mailing address

2183 RED BRIDGE RD
HORATIO AR
71842-8949
US

V. Phone/Fax

Practice location:
  • Phone: 870-642-6921
  • Fax:
Mailing address:
  • Phone: 870-582-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPD16296
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: