MEDICARE: EUSTACIO RIVAS JR.

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	31961	TX

General Provider Information

NPI Number	:	1780278408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EUSTACIO RIVAS JR.

Provider Business Mailing Address
First Line	:	1576 LOMALAND DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79935-4202
Country	:	US
Telephone Number	:	915-595-0409
Fax Number	:

Provider Business Practice Location Address
First Line	:	14476 HORIZON BLVD STE J
Second Line	:
City	:	HORIZON CITY
State	:	TX
Zip	:	79928-8579
Country	:	US
Telephone Number	:	915-852-8884
Fax Number	:	915-852-1727

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

Provider Enumeration Date	:	02/23/2021
Last Update Date	:	02/23/2021

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