Provider Demographics
NPI:1609198530
Name:RIVERA, MELBA N (RPH)
Entity type:Individual
Prefix:
First Name:MELBA
Middle Name:N
Last Name:RIVERA
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 1:2211 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-3980
Mailing Address - Country:US
Mailing Address - Phone:407-846-1109
Mailing Address - Fax:407-846-6574
Practice Address - Street 1:2211 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-3980
Practice Address - Country:US
Practice Address - Phone:407-846-1109
Practice Address - Fax:407-846-6574
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25595183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS25595OtherPHARMACIST STATE LICENSE NUMBER