Provider Demographics
NPI:1366779761
Name:RIVAS, SALVADOR JR
Entity type:Individual
Prefix:
First Name:SALVADOR
Middle Name:
Last Name:RIVAS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22928 W CANTILEVER ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-6247
Mailing Address - Country:US
Mailing Address - Phone:623-853-3436
Mailing Address - Fax:
Practice Address - Street 1:387 N ESTRELLA PKWY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9298
Practice Address - Country:US
Practice Address - Phone:623-215-1046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2012-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist