Healthcare Provider Details

I. General information

NPI: 1376073890
Provider Name (Legal Business Name): LUIS MANUEL RIVERA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 CALLE CAMBALACHE BO PAJAROS CANDELARIA
TOA BAJA PR
00949
US

IV. Provider business mailing address

PO BOX 2806
BAYAMON PR
00960-2806
US

V. Phone/Fax

Practice location:
  • Phone: 787-982-8300
  • Fax:
Mailing address:
  • Phone: 787-233-8928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number001104
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: