MEDICARE: DR. RANDY OMAR RIVERA AVILES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	006846	PR

General Provider Information

NPI Number	:	1194399485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDY OMAR RIVERA AVILES

Provider Business Mailing Address
First Line	:	PO BOX 44
Second Line	:
City	:	ANASCO
State	:	PR
Zip	:	00610-0044
Country	:	US
Telephone Number	:	787-826-4400
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 CALLE SAN ANTONIO
Second Line	:
City	:	ANASCO
State	:	PR
Zip	:	00610-2927
Country	:	US
Telephone Number	:	787-826-4400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2021
Last Update Date	:	05/19/2021

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