=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942844584
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISEL RIVERA-POLANCO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2019
-----------------------------------------------------
Last Update Date | 11/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9047 CURRY FORD RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-7604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-845-6530
-----------------------------------------------------
Fax | 407-845-6529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14818 FAVERSHAM CIR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32826-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-405-4428
-----------------------------------------------------
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 | PS40398
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------