Healthcare Provider Details

I. General information

NPI: 1538750708
Provider Name (Legal Business Name): LISHA MARIE RIVERA RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 04/30/2024
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 BROAD ST
HAZLETON PA
18201
US

IV. Provider business mailing address

1749 E BROAD ST
HAZLETON PA
18201
US

V. Phone/Fax

Practice location:
  • Phone: 570-454-3500
  • Fax:
Mailing address:
  • Phone: 570-454-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP454377P
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: