Healthcare Provider Details

I. General information

NPI: 1053824813
Provider Name (Legal Business Name): MANUEL RIVERA-SANTIAGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 AVE SIMON MADERA
SAN JUAN PR
00924-2231
US

IV. Provider business mailing address

1484 AVE FD ROOSEVELT APT 613
SAN JUAN PR
00920-2720
US

V. Phone/Fax

Practice location:
  • Phone: 787-751-0565
  • Fax: 787-763-1263
Mailing address:
  • Phone: 787-806-8137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number8670
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: