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General NPI Number Information
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NPI Number | 1982338992
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Entity Type | Individual
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Provider Name | JONATHAN LOUIS RIVERA
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Gender | Male
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Dates
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Enumeration Date | 07/14/2022
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Last Update Date | 07/14/2022
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Provider Practice Location Address
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Address Line | 600 S MAIN ST
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City | FORT WORTH
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State | TX
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Zip | 76104-2410
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Country | US
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Telephone | 831-238-7489
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Fax | 817-238-7489
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Provider Business Mailing Address
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Address Line | 2500 RIVER PARK DR APT 161
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City | FORT WORTH
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State | TX
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Zip | 76116-8434
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Country | US
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Telephone | 210-630-8457
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 39471
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License Number State | TX
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