Provider Demographics
NPI:1023614054
Name:ERIVES, TATIANA SELENE (RPH)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:SELENE
Last Name:ERIVES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 SEMINOLE LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-5565
Mailing Address - Country:US
Mailing Address - Phone:702-566-8664
Mailing Address - Fax:
Practice Address - Street 1:1402 E LAKE MEAD PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-4600
Practice Address - Country:US
Practice Address - Phone:702-558-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20663183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty