1659676450 NPI number — MICHELE DEMARCO RIVERA PHARM.D.

Table of content: MICHELE DEMARCO RIVERA PHARM.D. (NPI 1659676450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659676450 NPI number — MICHELE DEMARCO RIVERA PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
MICHELE
Provider Middle Name:
DEMARCO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GETTENS
Provider Other First Name:
MICHELE
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659676450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
765 ROCK HOUSE RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALESKA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-633-8705
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3760 SIXES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-8192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-345-8378
Provider Business Practice Location Address Fax Number:
770-882-0160
Provider Enumeration Date:
01/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH027407 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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