=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164027843
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS L RIVERA R PH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2020
-----------------------------------------------------
Last Update Date | 12/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 IVES DAIRY RD UNIT 8
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33179-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-652-0640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1460 SW 130TH AVE
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33325-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-243-8007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS31827
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------