Provider Demographics
NPI:1023164076
Name:RIVERA, JOHANNY
Entity type:Individual
Prefix:
First Name:JOHANNY
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:X4 CALLE ONIX
Mailing Address - Street 2:URB VALLE DE CERRO GORDO
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00957-6860
Mailing Address - Country:US
Mailing Address - Phone:787-243-3238
Mailing Address - Fax:
Practice Address - Street 1:76 CALLE DR VEVE
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-6306
Practice Address - Country:US
Practice Address - Phone:787-620-9600
Practice Address - Fax:787-740-3666
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2782183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician