Healthcare Provider Details

I. General information

NPI: 1780599340
Provider Name (Legal Business Name): NATHAN MALIK RIVERA AYALA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MAIN AVE
GARDINER ME
04345-2198
US

IV. Provider business mailing address

40 MAIN AVE
GARDINER ME
04345-2198
US

V. Phone/Fax

Practice location:
  • Phone: 207-582-3771
  • Fax:
Mailing address:
  • Phone: 207-582-3771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPR73319
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: